MEDICARE: PEDIATRIC DERMATOLOGY OF KANSAS CITY

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	207NP0225X	Pediatric Dermatology Physician

General Provider Information

NPI Number	:	1396211678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DERMATOLOGY OF KANSAS CITY

Provider Business Mailing Address
First Line	:	2001 SHAWNEE MISSION PKWY STE 130
Second Line	:
City	:	MISSION WOODS
State	:	KS
Zip	:	66205-2060
Country	:	US
Telephone Number	:	913-228-2000
Fax Number	:	855-354-0963

Provider Business Practice Location Address
First Line	:	2001 SHAWNEE MISSION PKWY
Second Line	:
City	:	MISSION WOODS
State	:	KS
Zip	:	66205-2007
Country	:	US
Telephone Number	:	913-339-8188
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	SUE ANN DOUGLAS
Credential	:	MD
Telephone Number	:	913-228-2000

Provider Enumeration Date	:	10/15/2018
Last Update Date	:	12/07/2023

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