Healthcare Provider Details

I. General information

NPI: 1710930490
Provider Name (Legal Business Name): PEDIATRIC PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 NE TUDOR RD
LEES SUMMIT MO
64086-5696
US

IV. Provider business mailing address

258 NE TUDOR RD
LEES SUMMIT MO
64086-5696
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-0303
  • Fax: 816-347-0160
Mailing address:
  • Phone: 816-347-0303
  • Fax: 816-347-0160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. TERESA M BRADY
Title or Position: OWNER/PHYSICIAN
Credential:
Phone: 816-347-0303