1447256037 NPI number — MICHAEL S FEDOTIN MD

Table of content: MICHAEL S FEDOTIN MD (NPI 1447256037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447256037 NPI number — MICHAEL S FEDOTIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEDOTIN
Provider First Name:
MICHAEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1447256037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2330 E MEYER BLVD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64132-1132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-333-5424
Provider Business Mailing Address Fax Number:
816-822-0870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2330 E MEYER BLVD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64132-1132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-333-5424
Provider Business Practice Location Address Fax Number:
816-822-0870
Provider Enumeration Date:
06/28/2005

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: 207RG0100X , with the licence number:  R3526 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 14275 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200079309 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100003018 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100005900A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com