Healthcare Provider Details

I. General information

NPI: 1205972270
Provider Name (Legal Business Name): LEE'S SUMMIT DERMATOLOGY ASSOCIATES I, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 NE TUDOR RD
LEE'S SUMMIT MO
64086-5696
US

IV. Provider business mailing address

276 NE TUDOR RD
LEE'S SUMMIT MO
64086-5696
US

V. Phone/Fax

Practice location:
  • Phone: 816-525-8500
  • Fax: 816-525-0185
Mailing address:
  • Phone: 816-525-8500
  • Fax: 816-525-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR9N60
License Number StateMO

VIII. Authorized Official

Name: GARY W MCEWEN
Title or Position: OWNER
Credential: M.D.
Phone: 816-525-8500