Healthcare Provider Details

I. General information

NPI: 1700021706
Provider Name (Legal Business Name): SHIVARAJAN MANICKAVASAGAM AMUDHAVALLI M.B.B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3000
  • Fax:
Mailing address:
  • Phone: 816-234-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number201029319
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP23802
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: