1619953155 NPI number — LANE DOUBENMIER MILLER MA

Table of content: LANE DOUBENMIER MILLER MA (NPI 1619953155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619953155 NPI number — LANE DOUBENMIER MILLER MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
LANE
Provider Middle Name:
DOUBENMIER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOUBENMIER
Provider Other First Name:
LANE'
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619953155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MAIN ST
Provider Second Line Business Mailing Address:
APT. 211
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64105-1277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-604-8598
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8801 E 63RD ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
RAYTOWN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64133-4875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-368-2000
Provider Business Practice Location Address Fax Number:
816-533-6873
Provider Enumeration Date:
12/16/2005

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: 101Y00000X , with the licence number:  2003032247 , 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: 497196303 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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