Healthcare Provider Details

I. General information

NPI: 1114258886
Provider Name (Legal Business Name): AB JETMORE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21106 W 95TH TER
LENEXA KS
66220-5600
US

IV. Provider business mailing address

PO BOX 7673
OVERLAND PARK KS
66207-0673
US

V. Phone/Fax

Practice location:
  • Phone: 913-322-8859
  • Fax: 888-778-9471
Mailing address:
  • Phone: 913-322-8859
  • Fax: 888-778-9471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number04-24436
License Number StateKS

VIII. Authorized Official

Name: DR. ALLEN BRUCE JETMORE
Title or Position: SOLE MEMBER
Credential: MD
Phone: 913-829-7716