1609902790 NPI number — DR. GINA MARIE PETELIN M.D.

Table of content: DR. GINA MARIE PETELIN M.D. (NPI 1609902790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609902790 NPI number — DR. GINA MARIE PETELIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETELIN
Provider First Name:
GINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
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:
SPALITTO
Provider Other First Name:
GINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609902790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 NE SAINT LUKES BLVD
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
LEES SUMMIT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64086-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-282-7809
Provider Business Mailing Address Fax Number:
816-282-7870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8919 PARALLEL PKWY STE 455
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:
66112-3628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-596-4929
Provider Business Practice Location Address Fax Number:
913-596-4982
Provider Enumeration Date:
02/26/2007

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: 207V00000X , with the licence number:  2009013714 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 04-32281 , 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: 200425800A , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".