Basic Information
| Provider Information | |||||||||
| NPI: | 1174559942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DATTILIO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 SHAWNEE MISSION PKWY | ||||||||
| Address2: | MEDICAL ADMINISTRATIVE SERVICES OF KU MED, STE. 312 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889000 | ||||||||
| FaxNumber: | 9135889822 | ||||||||
| Practice Location | |||||||||
| Address1: | 6420 N PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139459700 | ||||||||
| FaxNumber: | 9139459707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 107975 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080158296 | 01 | RR MEDICARE | OTHER | 481159444 | 01 | JAYHAWK TAX ID | OTHER | 157695XX | 01 | PREFERRED CARE OF NY | OTHER | 22039026 | 01 | BCBS PICTURE HILLS UC | OTHER | 18960020 | 01 | CFU BCBS | OTHER | 2057249 | 01 | AETNA | OTHER | 21968021 | 01 | BCBS PICTURE HILLS | OTHER | 10001644900 | 01 | CHP CREEKWOOD | OTHER | 21968011 | 01 | BCBS CREEKWOOD | OTHER |