Basic Information
| Provider Information | |||||||||
| NPI: | 1639119530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VESCOVO | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 SHAWNEE MISSION PKWY | ||||||||
| Address2: | MEDICAL ADMINISTRATIVE SERVICES OF KU MED, STE. 312 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889000 | ||||||||
| FaxNumber: | 9135889822 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 N. ANTIOCH | ||||||||
| Address2: | CREEKWOOD FAMILY CARE, STE. 12 | ||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164528000 | ||||||||
| FaxNumber: | 8164552382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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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 | R1330 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01887062 | 01 | BCBS PROVIDER NUMBER | OTHER | 157695XX | 01 | PREFERRED CARE OF NY | OTHER | 481159444 | 01 | TAX ID | OTHER | 110192165 | 01 | MO | RR MEDICARE NUMBER | OTHER | 2057250 | 01 | AETNA | OTHER | 18960020 | 01 | CFU BCBS NUMBER | OTHER |