Basic Information
| Provider Information | |||||||||
| NPI: | 1629517107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COCKERELL & MCINTOSH PEDIATRICS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 NW R D MIZE RD | ||||||||
| Address2: | STE 304 | ||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162284770 | ||||||||
| FaxNumber: | 8162281156 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 NW R D MIZE RD | ||||||||
| Address2: | STE 304 | ||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162284770 | ||||||||
| FaxNumber: | 8162281156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8162284770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 2016036885 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.