MEDICARE: SHOAL CREEK FAMILY MEDICINE AND ALLERGY, 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	207Q00000X	Family Medicine Physician	113071	MO

General Provider Information

NPI Number	:	1720183346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOAL CREEK FAMILY MEDICINE AND ALLERGY, PC

Provider Business Mailing Address
First Line	:	301 S PLATTE CLAY WAY
Second Line	:	SUITE B
City	:	KEARNEY
State	:	MO
Zip	:	64060-8214
Country	:	US
Telephone Number	:	816-903-8880
Fax Number	:	816-903-8884

Provider Business Practice Location Address
First Line	:	301 S PLATTE CLAY WAY
Second Line	:	SUITE B
City	:	KEARNEY
State	:	MO
Zip	:	64060-8214
Country	:	US
Telephone Number	:	816-903-8880
Fax Number	:	816-903-8884

Authorized Official
Title or Position	:	PHYSICIAN CO-OWNER
Name	:	MRS. ANGELA K STAPLETON
Credential	:	MD
Telephone Number	:	816-903-8880

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	08/22/2020

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