1124570080 NPI number — SIGNATURE MEDICAL GROUP OF KC, PA

Table of content: (NPI 1124570080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124570080 NPI number — SIGNATURE MEDICAL GROUP OF KC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIGNATURE MEDICAL GROUP OF KC, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1124570080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2016
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:
SUITE 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:
314-849-0311
Provider Business Mailing Address Fax Number:
314-849-4423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10777 NALL AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66211-1362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-642-0200
Provider Business Practice Location Address Fax Number:
913-563-6699
Provider Enumeration Date:
10/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
VEST
Authorized Official First Name:
JAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
314-849-0311

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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