Basic Information
Provider Information | |||||||||
NPI: | 1548780844 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLS | ||||||||
FirstName: | MANDALYN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KAUTZ | ||||||||
OtherFirstName: | MANDALYN | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5301 FARAON ST STE 120 | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MO | ||||||||
PostalCode: | 645063512 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162711066 | ||||||||
FaxNumber: | 8162716786 | ||||||||
Practice Location | |||||||||
Address1: | 802 N RIVERSIDE RD STE G50 | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MO | ||||||||
PostalCode: | 645072510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8166714888 | ||||||||
FaxNumber: | 8166714890 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2017 | ||||||||
LastUpdateDate: | 09/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5101023019 | MI | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 2022016390 | MO | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.