MEDICARE: STEPHEN EZELL

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	2471N0900X	Nuclear Medicine Technology Radiologic Technologist

General Provider Information

NPI Number	:	1942499439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN EZELL

Provider Business Mailing Address
First Line	:	4384 MILAM RD
Second Line	:
City	:	BATES CITY
State	:	MO
Zip	:	64011-8287
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4384 MILAM RD
Second Line	:
City	:	BATES CITY
State	:	MO
Zip	:	64011-8287
Country	:	US
Telephone Number	:	816-690-7650
Fax Number	:

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

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	10/19/2007

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