Healthcare Provider Details

I. General information

NPI: 1790733012
Provider Name (Legal Business Name): OLD WESTPORT ENT & ALLERGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 CARONDELET DR SUITE 450
KANSAS CITY MO
64114-4802
US

IV. Provider business mailing address

216 NW EXECUTIVE WAY
LEES SUMMIT MO
64063-1841
US

V. Phone/Fax

Practice location:
  • Phone: 816-942-7200
  • Fax: 816-942-2767
Mailing address:
  • Phone: 816-875-2599
  • Fax: 816-875-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEE ANN BOWLES
Title or Position: PRACTICE ADMINISTRATOR
Credential: BS,MS
Phone: 816-875-2599