=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356090880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S MERCY - PEACOCK PEDIATRICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2022
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 N 36TH ST STE B
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64506-2954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-396-6026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2401 GILLHAM RD ATTN: PROVIDER ENROLLMENT
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64108-4619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-701-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VICE PRESIDENT
-----------------------------------------------------
Name | ROBERT D FINUF II
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-701-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------