1255522009 NPI number — MIDWEST NEUROSCIENCE PC

Table of content: (NPI 1255522009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255522009 NPI number — MIDWEST NEUROSCIENCE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST NEUROSCIENCE PC
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:
1255522009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17020 E 40 HWY
Provider Second Line Business Mailing Address:
SUITE 8
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64055-5365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-373-3213
Provider Business Mailing Address Fax Number:
816-373-6209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17020 E 40 HWY
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64055-5365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-373-3213
Provider Business Practice Location Address Fax Number:
816-373-6209
Provider Enumeration Date:
08/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DONOHOE
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
816-373-3213

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  R7396 , 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: R7396 . This is a "LICENSE NUMBNER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 209250703 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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