MEDICARE: COCKERELL & MCINTOSH PEDIATRICS, PC

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	363LP0200X	Pediatric Nurse Practitioner	2016036885	MO

General Provider Information

NPI Number	:	1629517107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COCKERELL & MCINTOSH PEDIATRICS, PC

Provider Business Mailing Address
First Line	:	205 NW R D MIZE RD
Second Line	:	STE 304
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-2515
Country	:	US
Telephone Number	:	816-228-4770
Fax Number	:	816-228-1156

Provider Business Practice Location Address
First Line	:	205 NW R D MIZE RD
Second Line	:	STE 304
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64014-2515
Country	:	US
Telephone Number	:	816-228-4770
Fax Number	:	816-228-1156

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	BRYAN E WOOD
Credential	:
Telephone Number	:	816-228-4770

Provider Enumeration Date	:	02/17/2017
Last Update Date	:	02/17/2017

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