Healthcare Provider Details

I. General information

NPI: 1790537462
Provider Name (Legal Business Name): CHILDREN'S MERCY - JC PEDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 CHRISTY DR STE 210
JEFFERSON CITY MO
65101-5195
US

IV. Provider business mailing address

2401 GILLHAM RD ATTN: PROVIDER ENROLLMENT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 573-606-7337
  • Fax: 573-616-4459
Mailing address:
  • Phone: 816-701-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500099697
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: ROBERT D FINUF II
Title or Position: SNR VICE PRESIDENT
Credential:
Phone: 816-701-5200