Provider Demographics
NPI:1043313968
Name:WALLER, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:WALLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3901 RAINBOW BOULEVARD
Mailing Address - Street 2:6067 DELP, MAIL STOP 1028
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160
Mailing Address - Country:US
Mailing Address - Phone:913-588-6035
Mailing Address - Fax:913-945-6916
Practice Address - Street 1:3901 RAINBOW BOULEVARD
Practice Address - Street 2:6067 DELP, MAIL STOP 1028
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-6035
Practice Address - Fax:913-945-6916
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-05-08
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Provider Licenses
StateLicense IDTaxonomies
KS04-30882207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200263690AMedicaid
MO34056011OtherBCBS KC
KS580860OtherFIRSTGUARD
MO205362312Medicaid
KS200263690AMedicaid
MO34056011OtherBCBS KC
H41503Medicare UPIN