Healthcare Provider Details

I. General information

NPI: 1063411916
Provider Name (Legal Business Name): BRETT R HAILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 W 74TH ST
SHAWNEE MISSION KS
66204-4004
US

IV. Provider business mailing address

PO BOX 2747
SHAWNEE MISSION KS
66201-2747
US

V. Phone/Fax

Practice location:
  • Phone: 913-676-2214
  • Fax:
Mailing address:
  • Phone: 800-968-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD115613
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number115613
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: