Provider Demographics
NPI: | 1114924578 |
---|---|
Name: | CONNOR, MICHAEL J (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | J |
Last Name: | CONNOR |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2330 E MEYER BLVD |
Mailing Address - Street 2: | SUITE 301 |
Mailing Address - City: | KANSAS CITY |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 64132-1132 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 816-333-5424 |
Mailing Address - Fax: | 816-822-0870 |
Practice Address - Street 1: | 2330 E MEYER BLVD |
Practice Address - Street 2: | SUITE 301 |
Practice Address - City: | KANSAS CITY |
Practice Address - State: | MO |
Practice Address - Zip Code: | 64132-1132 |
Practice Address - Country: | US |
Practice Address - Phone: | 816-333-5424 |
Practice Address - Fax: | 816-822-0870 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-30 |
Last Update Date: | 2016-01-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2003005215 | 207RG0100X |
KS | 04-27001 | 207RG0100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 100642590A | Medicaid | |
MO | 206074601 | Medicaid | |
P00045637 | Other | RR MEDICARE | |
KS | 100642590A | Medicaid | |
P00045637 | Other | RR MEDICARE |