Basic Information
| Provider Information | |||||||||
| NPI: | 1467729988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIGNATURE MEDICAL GROU P OF KC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10701 NALL AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133815225 | ||||||||
| FaxNumber: | 9139010186 | ||||||||
| Practice Location | |||||||||
| Address1: | 12639 OLD TESSON RD | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148490311 | ||||||||
| FaxNumber: | 3148494423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2011 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | STEPHENSON | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTATOR | ||||||||
| AuthorizedOfficialTelephone: | 9133815225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 6684440001 | 01 | KS | MEDICARE PTAN | OTHER |