Provider Demographics
NPI:1033195540
Name:BREMEN, ROXANE S (DO)
Entity Type:Individual
Prefix:DR
First Name:ROXANE
Middle Name:S
Last Name:BREMEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 SW 3RD ST
Mailing Address - Street 2:STE B
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2280
Mailing Address - Country:US
Mailing Address - Phone:816-398-7048
Mailing Address - Fax:913-562-9972
Practice Address - Street 1:622 SW 3RD ST
Practice Address - Street 2:STE B
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2280
Practice Address - Country:US
Practice Address - Phone:816-398-7048
Practice Address - Fax:913-562-9972
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1050582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033195540Medicaid
KS0524537OtherKANSAS LICENSE
MO105058OtherMISSOURI LICENSE
MOF90077Medicare UPIN
MO105058OtherMISSOURI LICENSE