Basic Information
Provider Information | |||||||||
NPI: | 1144485533 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | JEANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HLADKY | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | JEANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 804408 | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641804408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9136424900 | ||||||||
FaxNumber: | 9133810979 | ||||||||
Practice Location | |||||||||
Address1: | 2525 GLENN HENDREN DR | ||||||||
Address2: |   | ||||||||
City: | LIBERTY | ||||||||
State: | MO | ||||||||
PostalCode: | 640689625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8167927126 | ||||||||
FaxNumber: | 8167927196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2008 | ||||||||
LastUpdateDate: | 07/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2008016062 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | P00639280 | 01 | MO | RR MEDICARE | OTHER | 1144485533 | 05 | MO |   | MEDICAID |