MEDICARE: WANLESS EAR, NOSE & THROAT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician		MO

General Provider Information

NPI Number	:	1083689889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WANLESS EAR, NOSE & THROAT LLC

Provider Business Mailing Address
First Line	:	1513 UNION AVE STE 1200
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-9405
Country	:	US
Telephone Number	:	660-263-4600
Fax Number	:	660-263-4640

Provider Business Practice Location Address
First Line	:	1513 UNION AVE STE 1200
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-9405
Country	:	US
Telephone Number	:	660-263-4600
Fax Number	:	660-263-4640

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	KIRK M. WANLESS
Credential	:	MD
Telephone Number	:	660-263-4600

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	03/03/2020

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