Provider Demographics
NPI:1164476339
Name:MIDWEST AORTIC & VASCULAR INSTITUTE, P.C.
Entity Type:Organization
Organization Name:MIDWEST AORTIC & VASCULAR INSTITUTE, P.C.
Other - Org Name:KANSAS CITY VASCULAR, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-872-1601
Mailing Address - Street 1:2750 CLAY EDWARDS DRIVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116
Mailing Address - Country:US
Mailing Address - Phone:816-842-5555
Mailing Address - Fax:816-659-9123
Practice Address - Street 1:2750 CLAY EDWARDS DRIVE
Practice Address - Street 2:SUITE 304
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116
Practice Address - Country:US
Practice Address - Phone:816-842-5555
Practice Address - Fax:816-659-9123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF670000Medicare PIN