Provider Demographics
NPI:1275599417
Name:WICKLUND, BRIAN MONTGOMERY (MDCM, MPH)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MONTGOMERY
Last Name:WICKLUND
Suffix:
Gender:M
Credentials:MDCM, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-234-3000
Mailing Address - Fax:
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-234-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8H412080P0207X
KS04-230442080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202615506Medicaid
KS100117230AMedicaid
MO202615506Medicaid