Basic Information
| Provider Information | |||||||||
| NPI: | 1811995129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALDSCHMIDT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2750 CLAY EDWARDS DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641163256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168425555 | ||||||||
| FaxNumber: | 8168428888 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168425555 | ||||||||
| FaxNumber: | 8168428888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | R2E49 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 202238903 | 05 | MO | MEDICAID |