1023240959 NPI number — BETHANY A FREDERICKS OTR

Table of content: BETHANY A FREDERICKS OTR (NPI 1023240959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023240959 NPI number — BETHANY A FREDERICKS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICKS
Provider First Name:
BETHANY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1023240959
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8829 N CONGRESS AVE
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:
64153-1891
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-896-6400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 GREELEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66104-2647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-896-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2009

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: 225X00000X , with the licence number:  T-02552 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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