Healthcare Provider Details

I. General information

NPI: 1952781726
Provider Name (Legal Business Name): MAHALETWORK ASSEFA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 N RIVERSIDE RD STE 100
SAINT JOSEPH MO
64507-2566
US

IV. Provider business mailing address

PO BOX 843966 DC043.00
KANSAS CITY MO
64184-3966
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-1241
  • Fax: 816-279-7794
Mailing address:
  • Phone: 573-884-3300
  • Fax: 573-884-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2018015281
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2018015281
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2015017112
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: