MEDICARE: DR. JOHN A GILLEN II 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	110898	MO
2	207X00000X	Orthopaedic Surgery Physician	30353	KS

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
2	23296023	OTHER	MO	BCBS INDIVIDUAL #
3	607374400	OTHER	MO	DEPT OF LABOR
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	17519026	OTHER	MO	BCBS GROUP #

General Provider Information

NPI Number	:	1881696136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN A GILLEN II M.D.

Provider Business Mailing Address
First Line	:	900 MAIN ST
Second Line	:
City	:	GRANDVIEW
State	:	MO
Zip	:	64030-2477
Country	:	US
Telephone Number	:	816-331-6700
Fax Number	:	816-876-2399

Provider Business Practice Location Address
First Line	:	900 MAIN ST
Second Line	:
City	:	GRANDVIEW
State	:	MO
Zip	:	64030-2477
Country	:	US
Telephone Number	:	816-331-6700
Fax Number	:	816-876-2399

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	02/27/2012

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