Healthcare Provider Details

I. General information

NPI: 1871572792
Provider Name (Legal Business Name): EVERETTE THEODORE SITZMAN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 W 94TH TER STE 105
PRAIRIE VILLAGE KS
66207-2522
US

IV. Provider business mailing address

5200 W 94TH TER STE 105
PRAIRIE VILLAGE KS
66207-2522
US

V. Phone/Fax

Practice location:
  • Phone: 913-649-5567
  • Fax: 913-649-7563
Mailing address:
  • Phone: 913-649-5567
  • Fax: 913-649-7563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number04 22079
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number04 22079
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: