Basic Information
Provider Information | |||||||||
NPI: | 1699082776 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLS | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7405 RENNER RD | ||||||||
Address2: |   | ||||||||
City: | SHAWNEE | ||||||||
State: | KS | ||||||||
PostalCode: | 662179414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9135888400 | ||||||||
FaxNumber: | 9135888529 | ||||||||
Practice Location | |||||||||
Address1: | 7405 RENNER RD | ||||||||
Address2: | KU MEDWEST | ||||||||
City: | SHAWNEE | ||||||||
State: | KS | ||||||||
PostalCode: | 662179414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9135888400 | ||||||||
FaxNumber: | 9135888529 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2010 | ||||||||
LastUpdateDate: | 03/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | R5F40 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | 04-20763 | KS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 100203230C | 05 | KS |   | MEDICAID | 12737090 | 01 |   | BCBS OF KANSAS CITY | OTHER |