Provider Demographics
NPI:1073514733
Name:FANNING, MARTHA SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:SUE
Last Name:FANNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:SUE
Other - Last Name:PACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 411039
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1039
Mailing Address - Country:US
Mailing Address - Phone:913-234-1350
Mailing Address - Fax:
Practice Address - Street 1:12300 METCALF AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1324
Practice Address - Country:US
Practice Address - Phone:913-317-7485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26640207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100333210CMedicaid
MO24548088OtherBCBS KC MO
KS01674018OtherBCBS KC MO GRP 01674018
KS100333210EMedicaid
KS24548068OtherBCBS KC MO
P00278183OtherRR MEDICARE GROUP DC6712
MO208531038Medicaid
930072754OtherRR MEDICARE GROUP CC8899
P00278183OtherRR MEDICARE GROUP DC6712
MO208531038Medicaid
930072754OtherRR MEDICARE GROUP CC8899