Healthcare Provider Details

I. General information

NPI: 1104855683
Provider Name (Legal Business Name): MICHAEL SCOTT BLUBAUGH MSPT,LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N 2ND ST
ODESSA MO
64076-1135
US

IV. Provider business mailing address

2318 SOMERSET DR
PRAIRIE VILLAGE KS
66206-1244
US

V. Phone/Fax

Practice location:
  • Phone: 816-633-4063
  • Fax: 816-230-3230
Mailing address:
  • Phone: 913-526-7220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-01870
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number117614
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: