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General NPI Number Information
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NPI Number | 1679881767
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Entity Type | Organization
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Legal Business Name | PEDIATRIC HEADACHE CENTER PC
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Dates
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Enumeration Date | 09/22/2010
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Last Update Date | 09/22/2010
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Provider Practice Location Address
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Address Line | 400 E RED BRIDGE RD SUITE 206
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City | KANSAS CITY
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State | MO
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Zip | 64131-4035
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Country | US
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Telephone | 816-509-3363
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Fax |
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Provider Business Mailing Address
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Address Line | 400 E RED BRIDGE RD SUITE 206
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City | KANSAS CITY
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State | MO
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Zip | 64131-4035
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Country | US
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Telephone | 816-509-3363
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | GERRY R. GERRY
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Credential | MD
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Telephone | 816-509-3363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 105950
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License Number State | MO
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