Basic Information
| Provider Information | |||||||||
| NPI: | 1811927114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 BROADWAY | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165314080 | ||||||||
| FaxNumber: | 8165310281 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 BROADWAY | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165314080 | ||||||||
| FaxNumber: | 8165310281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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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 | 2084N0400X | L3965 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 2015008268 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1811927114 | 05 | MO | MEDICAID |