MEDICARE: BERT E PARK MD

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	207T00000X	Neurological Surgery Physician	R7A63	MO

General Provider Information

NPI Number	:	1407841851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERT E PARK MD

Provider Business Mailing Address
First Line	:	1515 W TRUMAN RD
Second Line	:	SUITE 607
City	:	INDEPENDENCE
State	:	MO
Zip	:	64050-3436
Country	:	US
Telephone Number	:	816-833-0466
Fax Number	:	816-833-4155

Provider Business Practice Location Address
First Line	:	1515 W TRUMAN RD
Second Line	:	SUITE 607
City	:	INDEPENDENCE
State	:	MO
Zip	:	64050-3436
Country	:	US
Telephone Number	:	816-833-0466
Fax Number	:	816-833-4155

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	08/14/2007

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