MEDICARE: EVERETTE THEODORE SITZMAN JR. MD

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	2084P0800X	Psychiatry Physician	04 22079	KS
2	2084P0805X	Geriatric Psychiatry Physician	04 22079	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15094011	OTHER		BC BS OF KC

General Provider Information

NPI Number	:	1871572792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVERETTE THEODORE SITZMAN JR. MD

Provider Business Mailing Address
First Line	:	5200 W 94TH TER
Second Line	:	STE 105
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2522
Country	:	US
Telephone Number	:	913-649-5567
Fax Number	:	913-649-7563

Provider Business Practice Location Address
First Line	:	5200 W 94TH TER
Second Line	:	STE 105
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2522
Country	:	US
Telephone Number	:	913-649-5567
Fax Number	:	913-649-7563

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	05/25/2010

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