MEDICARE: PRIMARY CARE NORTH KANSAS CITY 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	207Q00000X	Family Medicine Physician	106031	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518173632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE NORTH KANSAS CITY LLC

Provider Business Mailing Address
First Line	:	5861 NW 72ND ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-1483
Country	:	US
Telephone Number	:	816-741-2286
Fax Number	:	816-587-2436

Provider Business Practice Location Address
First Line	:	5861 NW 72ND ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64151-1483
Country	:	US
Telephone Number	:	816-741-2286
Fax Number	:	816-587-2436

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. BLAKE H DONALDSON
Credential	:	D.O.
Telephone Number	:	816-741-2286

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	03/27/2013

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