Basic Information
Provider Information | |||||||||
NPI: | 1235180142 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANDYKE | ||||||||
FirstName: | ELMER | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3131 BRIANNA BLVD | ||||||||
Address2: |   | ||||||||
City: | SEDALIA | ||||||||
State: | MO | ||||||||
PostalCode: | 653012285 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608261381 | ||||||||
FaxNumber: | 6608273001 | ||||||||
Practice Location | |||||||||
Address1: | 3131 BRIANNA BLVD | ||||||||
Address2: |   | ||||||||
City: | SEDALIA | ||||||||
State: | MO | ||||||||
PostalCode: | 653012285 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6608261381 | ||||||||
FaxNumber: | 6608273001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2006 | ||||||||
LastUpdateDate: | 04/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 27057 | MO | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 174400000X | 27057 | MO | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 01881013 | 01 | MO | BLUE CROSS BLUES SHIELD | OTHER | 200437408 | 05 | MO |   | MEDICAID |