1417052614 NPI number — WILLIAM ALBERT MOFFITT PHD

Table of content: WILLIAM ALBERT MOFFITT PHD (NPI 1417052614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417052614 NPI number — WILLIAM ALBERT MOFFITT PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOFFITT
Provider First Name:
WILLIAM
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

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:
1417052614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18955 WEST 116TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLATHE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-888-2362
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 S 4TH STREET
Provider Second Line Business Practice Location Address:
PROFESSIONAL ASSOCIATION
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-651-8415
Provider Business Practice Location Address Fax Number:
913-772-8580
Provider Enumeration Date:
09/13/2006

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: 103T00000X , with the licence number:  675 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: R0333 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 19924039 . This is a "BCBS OF KC KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 004517 . This is a "GROUP BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 2008188 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 066956 . This is a "BCBS OF KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: B011 . This is a "PHYSICIAN SERVICES TRICAR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4285605 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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