=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649379447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH B. PETELIN, M.D., CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9119 W 74TH ST SUITE 255
-----------------------------------------------------
City | SHAWNEE MISSION
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66204-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-432-5420
-----------------------------------------------------
Fax | 913-432-7749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9119 W 74TH ST SUITE 255
-----------------------------------------------------
City | SHAWNEE MISSION
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66204-2236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-432-5420
-----------------------------------------------------
Fax | 913-432-7749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OF THE PRACTICE
-----------------------------------------------------
Name | DR. JOSEPH B. PETELIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 913-432-5420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 417417
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------