1619927720 NPI number — DR. BRANDON D POMEROY MD

Table of content: DR. BRANDON D POMEROY MD (NPI 1619927720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619927720 NPI number — DR. BRANDON D POMEROY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POMEROY
Provider First Name:
BRANDON
Provider Middle Name:
D
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:
1619927720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8551 BLUEJACKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENEXA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66214-1656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-341-7985
Provider Business Mailing Address Fax Number:
913-341-7988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4321 WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 5300
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64111-5961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-531-1234
Provider Business Practice Location Address Fax Number:
816-531-0737
Provider Enumeration Date:
05/11/2006

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: 174400000X , with the licence number:  04-27485 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 2001023021 , 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: 100315140C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 205752603 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340019585 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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