Provider Demographics
NPI:1336281534
Name:DR. J.A. DIRENNA JR, P.C.
Entity Type:Organization
Organization Name:DR. J.A. DIRENNA JR, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIRENNA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:816-225-1643
Mailing Address - Street 1:PO BOX 2181
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-0081
Mailing Address - Country:US
Mailing Address - Phone:913-248-9693
Mailing Address - Fax:913-248-9383
Practice Address - Street 1:1 THE WOODLANDS
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64119-1853
Practice Address - Country:US
Practice Address - Phone:816-225-1643
Practice Address - Fax:913-248-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6C32207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19739014OtherBLUE SHIELD KC
MO19739014OtherBLUE SHIELD KC
MO4250000AMedicare ID - Type Unspecified