Provider Demographics
NPI:1083689889
Name:WANLESS EAR, NOSE & THROAT LLC
Entity Type:Organization
Organization Name:WANLESS EAR, NOSE & THROAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:M
Authorized Official - Last Name:WANLESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-263-4600
Mailing Address - Street 1:1513 UNION AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9405
Mailing Address - Country:US
Mailing Address - Phone:660-263-4600
Mailing Address - Fax:660-263-4640
Practice Address - Street 1:1513 UNION AVE STE 1200
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9405
Practice Address - Country:US
Practice Address - Phone:660-263-4600
Practice Address - Fax:660-263-4640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00014765Medicare ID - Type Unspecified
MODD9041Medicare PIN