Healthcare Provider Details

I. General information

NPI: 1386609196
Provider Name (Legal Business Name): PRADEEP PA MAMMEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CAMBRIDGE ST STE G600
KANSAS CITY KS
66160-8501
US

IV. Provider business mailing address

4000 CAMBRIDGE ST STE G600
KANSAS CITY KS
66160-8501
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-9600
  • Fax:
Mailing address:
  • Phone: 913-588-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberK6884
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number04-47191
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: