Healthcare Provider Details

I. General information

NPI: 1063489631
Provider Name (Legal Business Name): MARK REDICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 SHAWNEE MISSION PKWY
WESTWOOD KS
66205-2005
US

IV. Provider business mailing address

PO BOX 411851
KANSAS CITY MO
64141-1851
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-6805
  • Fax: 913-588-7899
Mailing address:
  • Phone: 913-588-6805
  • Fax: 913-588-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number111830
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-24522
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: