1649379447 NPI number — JOSEPH B. PETELIN, M.D., CHARTERED

Table of content: (NPI 1649379447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649379447 NPI number — JOSEPH B. PETELIN, M.D., CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH B. PETELIN, M.D., CHARTERED
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:
1649379447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9119 W 74TH ST
Provider Second Line Business Mailing Address:
SUITE 255
Provider Business Mailing Address City Name:
SHAWNEE MISSION
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66204-2236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-432-5420
Provider Business Mailing Address Fax Number:
913-432-7749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9119 W 74TH ST
Provider Second Line Business Practice Location Address:
SUITE 255
Provider Business Practice Location Address City Name:
SHAWNEE MISSION
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66204-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-432-5420
Provider Business Practice Location Address Fax Number:
913-432-7749
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETELIN
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER OF THE PRACTICE
Authorized Official Telephone Number:
913-432-5420

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  417417 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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