1649898693 NPI number — MATTHEW D MCKENNA PT

Table of content: MATTHEW D MCKENNA PT (NPI 1649898693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649898693 NPI number — MATTHEW D MCKENNA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKENNA
Provider First Name:
MATTHEW
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1649898693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 219297
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64121-9297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-775-4747
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 E NORTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64012-2128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-775-4747
Provider Business Practice Location Address Fax Number:
833-964-0159
Provider Enumeration Date:
07/07/2020

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: 225100000X , with the licence number:  1106463 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2023020721 , 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: 1106463 . This is a "LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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