Healthcare Provider Details

I. General information

NPI: 1669624896
Provider Name (Legal Business Name): GARY Y SHAW MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 NE TUDOR RD
LEES SUMMIT MO
64086-5696
US

IV. Provider business mailing address

296 NE TUDOR RD
LEES SUMMIT MO
64086-5696
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-4890
  • Fax: 816-524-4888
Mailing address:
  • Phone: 816-524-4890
  • Fax: 816-524-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number109774
License Number StateMO

VIII. Authorized Official

Name: DR. GARY Y SHAW
Title or Position: PRESIDENT
Credential: M.D.
Phone: 816-524-4890