Healthcare Provider Details

I. General information

NPI: 1083653018
Provider Name (Legal Business Name): JAMES KELLY MCENTIRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 NW MCNARY CT
LEES SUMMIT MO
64086-4011
US

IV. Provider business mailing address

241 NW MCNARY CT
LEES SUMMIT MO
64086-4011
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-0064
  • Fax: 816-347-0593
Mailing address:
  • Phone: 816-347-0064
  • Fax: 816-347-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number101255
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier24812488
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: