Basic Information
| Provider Information | |||||||||
| NPI: | 1306824735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLDREY | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801143 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315583 | ||||||||
| FaxNumber: | 5733315079 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734310330 | ||||||||
| FaxNumber: | 5734710461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2005022494 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 430741410 | 01 | MO | FIRST HEALTH NUMBER | OTHER | 730776 | 01 | MO | HEALTHLINK | OTHER | 199827 | 01 | MO | BCBS MO NUMBER | OTHER | 207266701 | 05 | MO | MEDICAID |