1194763524 NPI number — TERRY D SUPPES DO

Table of content: TERRY D SUPPES DO (NPI 1194763524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194763524 NPI number — TERRY D SUPPES DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUPPES
Provider First Name:
TERRY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1194763524
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6675 HOLMES RD
Provider Second Line Business Mailing Address:
SUITE 450
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64131-1150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-276-7600
Provider Business Mailing Address Fax Number:
816-276-7090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6675 HOLMES RD
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64131-1150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-276-7600
Provider Business Practice Location Address Fax Number:
816-276-7992
Provider Enumeration Date:
06/04/2006

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: 207Q00000X , with the licence number:  36974 , 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: 100234880C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 243112612 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00121096 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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