Provider Demographics
NPI:1114258886
Name:AB JETMORE MD LLC
Entity Type:Organization
Organization Name:AB JETMORE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:JETMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-829-7716
Mailing Address - Street 1:PO BOX 7673
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-0673
Mailing Address - Country:US
Mailing Address - Phone:913-322-8859
Mailing Address - Fax:888-778-9471
Practice Address - Street 1:21106 W 95TH TER
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66220-5600
Practice Address - Country:US
Practice Address - Phone:913-322-8859
Practice Address - Fax:888-778-9471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24436208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4221151OtherAETNA
MO42525017OtherBLUE SHIELD KANSAS CITY
KS4221151OtherAETNA