Basic Information
| Provider Information | |||||||||
| NPI: | 1386955334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETELIN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E. 104TH ST | ||||||||
| Address2: | MAILSTOP 400N | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165027104 | ||||||||
| FaxNumber: | 8169329670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4321 WASHINGTON ST STE 3000 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169323100 | ||||||||
| FaxNumber: | 8169326871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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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 | 207R00000X | 0536409 | KS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2016028966 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.