Basic Information
| Provider Information | |||||||||
| NPI: | 1891775920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4320 WORNALL RD | ||||||||
| Address2: | SUITE 50 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169313312 | ||||||||
| FaxNumber: | 8165319862 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 WORNALL RD | ||||||||
| Address2: | SUITE 50 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169313312 | ||||||||
| FaxNumber: | 8165319862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
| 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 | 208G00000X | 2010001724 | MO | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 04-34175 | KS | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | MA1815 | 01 | MO | MEDICARE | OTHER | 149549001 | 05 | AR | MEDICAID | 209231208 | 05 | MO | MEDICAID | 200009120A | 05 | OK | MEDICAID |