Healthcare Provider Details

I. General information

NPI: 1063674596
Provider Name (Legal Business Name): BENJAMIN RICHARD ALSOP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 NE SAINT LUKES BLVD STE 530
LEES SUMMIT MO
64086
US

IV. Provider business mailing address

110 NE SAINT LUKES BLVD STE 530
LEES SUMMIT MO
64086-6075
US

V. Phone/Fax

Practice location:
  • Phone: 816-554-3838
  • Fax: 816-554-1634
Mailing address:
  • Phone: 816-554-3838
  • Fax: 816-554-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number04-35016
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2018011080
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: