Basic Information
Provider Information | |||||||||
NPI: | 1437154614 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZINN | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | WILDER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5800 FOXRIDGE DR | ||||||||
Address2: | STE 240 | ||||||||
City: | MISSION | ||||||||
State: | KS | ||||||||
PostalCode: | 662022338 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9132613153 | ||||||||
FaxNumber: | 9132623295 | ||||||||
Practice Location | |||||||||
Address1: | 8929 PARALLEL PKWY | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 661121689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9135964862 | ||||||||
FaxNumber: | 9135964635 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2005 | ||||||||
LastUpdateDate: | 07/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 04-14018 | KS | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2005009948 | MO | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 100200980B | 05 | KS |   | MEDICAID | 200837417 | 05 | MO |   | MEDICAID | 100200980 | 05 | KS |   | MEDICAID |