MEDICARE: DR. MICHAEL GABRIEL AZZAM M.D.

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	207X00000X	Orthopaedic Surgery Physician	2016016714	MO
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	04-41486	KS
3	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	2016016714	MO
4	207X00000X	Orthopaedic Surgery Physician	04-41486	KS

General Provider Information

NPI Number	:	1215258736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL GABRIEL AZZAM M.D.

Provider Business Mailing Address
First Line	:	5200 W 94TH TER STE 113
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2522
Country	:	US
Telephone Number	:	913-906-8640
Fax Number	:	913-906-8682

Provider Business Practice Location Address
First Line	:	5200 W 94TH TER STE 113
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2522
Country	:	US
Telephone Number	:	913-906-8640
Fax Number	:	913-906-8682

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2010
Last Update Date	:	06/18/2021

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