Healthcare Provider Details

I. General information

NPI: 1255777561
Provider Name (Legal Business Name): TREVOR BLEDSOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 WINCHESTER AVE STE 230
KANSAS CITY MO
64133
US

IV. Provider business mailing address

6601 WINCHESTER AVE STE 230
KANSAS CITY MO
64133-4681
US

V. Phone/Fax

Practice location:
  • Phone: 816-313-2677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number54508
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2018010585
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: