Basic Information
| Provider Information | |||||||||
| NPI: | 1073774188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YURI TSIRULNIKOV DO MHA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5624 W 134TH TER APT 1435 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662094056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3195415940 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167817200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | TSIRULNIKOV | ||||||||
| AuthorizedOfficialFirstName: | YURI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3195415940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 2008010728 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2008010728 | 01 | MO | MO LICENSE | OTHER |