Healthcare Provider Details

I. General information

NPI: 1104949304
Provider Name (Legal Business Name): NEIL JOSEPH MARDIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 06/20/2011
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

8422 N ARCOLA AVE
KANSAS CITY MO
64153-2871
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3000
  • Fax:
Mailing address:
  • Phone: 816-582-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number2008013757
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: