Basic Information
| Provider Information | |||||||||
| NPI: | 1659364164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11157 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641190157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341350 | ||||||||
| FaxNumber: | 9132341108 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 CLAY EDWARDS DR | ||||||||
| Address2: | |||||||||
| City: | NORTH KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641163220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163467220 | ||||||||
| FaxNumber: | 8163467242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | R8N03 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0005X | R8N03 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 19133017 | 01 | MO | BCBS KC MO | OTHER | 19133027 | 01 | MO | BCBS KC MO WOUND CARE | OTHER | 930016992 | 01 | RR MEDICARE GROUP CD1534 | OTHER | P00604070 | 01 | MO | RR MEDICARE GROUP DN0988 | OTHER | 19133027 | 01 | MO | BCBS MO WOUND CARE | OTHER | 202930913 | 05 | MO | MEDICAID |