1578797049 NPI number — MARJORIE MAE WONGSKHALUANG M.D.

Table of content: MARJORIE MAE WONGSKHALUANG M.D. (NPI 1578797049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578797049 NPI number — MARJORIE MAE WONGSKHALUANG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONGSKHALUANG
Provider First Name:
MARJORIE
Provider Middle Name:
MAE
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:
CONANT
Provider Other First Name:
MARJORIE
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578797049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 W 109TH ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211-1313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-942-0540
Provider Business Mailing Address Fax Number:
630-528-9589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2340 E MEYER BLVD, BLDG 2
Provider Second Line Business Practice Location Address:
SUITE 392
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64132-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-444-7977
Provider Business Practice Location Address Fax Number:
630-528-9578
Provider Enumeration Date:
05/12/2009

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: 207RI0200X , with the licence number:  04-37750 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 2014015768 , 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)





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