1174623540 NPI number — DR. BRADLEY J CONDON MD

Table of content: DR. BRADLEY J CONDON MD (NPI 1174623540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174623540 NPI number — DR. BRADLEY J CONDON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONDON
Provider First Name:
BRADLEY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174623540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 412431
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64141-2431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-647-4100
Provider Business Mailing Address Fax Number:
913-647-4120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NE SAINT LUKES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEES SUMMIT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64086-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-347-5097
Provider Business Practice Location Address Fax Number:
816-347-5045
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  04-29441 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 04-29441 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 2003009757 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200005950A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 456741 . This is a "FIRSTGUARD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 33270024 . This is a "BCBS KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 209028711 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01207986 . This is a "RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com