Healthcare Provider Details

I. General information

NPI: 1053362681
Provider Name (Legal Business Name): MATTHEW CIANCIOLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 NE SAINT LUKES BLVD STE. 200
LEES SUMMIT MO
64086-6001
US

IV. Provider business mailing address

901 E. 104TH ST. MAILSTOP 400N
KANSAS CITY MO
64131-9712
US

V. Phone/Fax

Practice location:
  • Phone: 813-347-5100
  • Fax: 816-347-5136
Mailing address:
  • Phone: 816-502-7104
  • Fax: 816-932-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006004613
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: