Healthcare Provider Details

I. General information

NPI: 1861074742
Provider Name (Legal Business Name): SAMUEL CODY BROLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20375 W 151ST ST STE 409
OLATHE KS
66061-7210
US

IV. Provider business mailing address

2028 BRISTOW ST
KANSAS CITY KS
66103-2111
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-1227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number04-51473
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2025047602
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number04-51473
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number2025047602
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: