Healthcare Provider Details

I. General information

NPI: 1447256037
Provider Name (Legal Business Name): MICHAEL S FEDOTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 E MEYER BLVD SUITE 301
KANSAS CITY MO
64132-1132
US

IV. Provider business mailing address

2330 E MEYER BLVD SUITE 301
KANSAS CITY MO
64132-1132
US

V. Phone/Fax

Practice location:
  • Phone: 816-333-5424
  • Fax: 816-822-0870
Mailing address:
  • Phone: 816-333-5424
  • Fax: 816-822-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberR3526
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number14275
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: