Basic Information
| Provider Information | |||||||||
| NPI: | 1922047646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E 104TH ST | ||||||||
| Address2: | MAILSTOP 400 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165028755 | ||||||||
| FaxNumber: | 8169329670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 WORNALL RD | ||||||||
| Address2: | STE 530 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169322836 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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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 | 208600000X | 113158 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 0429748 | KS | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1922047646 | 05 | MO | MEDICAID |