1467729988 NPI number — SIGNATURE MEDICAL GROUP OF KC, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467729988 NPI number — SIGNATURE MEDICAL GROUP OF KC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIGNATURE MEDICAL GROUP OF KC, P.A.
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:
1467729988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10701 NALL AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211-1363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-381-5225
Provider Business Mailing Address Fax Number:
913-901-0186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12639 OLD TESSON RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-849-0311
Provider Business Practice Location Address Fax Number:
314-849-4423
Provider Enumeration Date:
11/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENSON
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTATOR
Authorized Official Telephone Number:
913-381-5225

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)

  • Identifier: 6684440001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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