MEDICARE: EVANS PEDIATRIC CLINIC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	110143	MO

General Provider Information

NPI Number	:	1013952886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANS PEDIATRIC CLINIC PC

Provider Business Mailing Address
First Line	:	3912 SHERMAN AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-3648
Country	:	US
Telephone Number	:	816-233-5959
Fax Number	:	816-233-5960

Provider Business Practice Location Address
First Line	:	3912 SHERMAN AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64506-3648
Country	:	US
Telephone Number	:	816-233-5959
Fax Number	:	816-233-5960

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DOUGLAS EUGENE EVANS
Credential	:	D.O.
Telephone Number	:	816-351-6385

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	11/28/2011

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