1477655785 NPI number — LYNNE E KALLENBACH M.D.

Table of content: LYNNE E KALLENBACH M.D. (NPI 1477655785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477655785 NPI number — LYNNE E KALLENBACH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALLENBACH
Provider First Name:
LYNNE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1477655785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12639 OLD TESSON RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-2786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-451-8500
Provider Business Mailing Address Fax Number:
913-451-8575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12140 NALL AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66209-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-451-8500
Provider Business Practice Location Address Fax Number:
913-451-8575
Provider Enumeration Date:
09/05/2006

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: 207RG0300X , with the licence number:  04-30715 , 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)

  • Identifier: 927267 . This is a "FIRSTGUARD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100066940B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35463015 . This is a "BCBS KC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 207217308 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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