Provider Demographics
NPI:1396832754
Name:REDMON, MARY L (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:REDMON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411851
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1851
Mailing Address - Country:US
Mailing Address - Phone:913-588-1944
Mailing Address - Fax:913-588-2496
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:MS 4017
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8500
Practice Address - Country:US
Practice Address - Phone:913-588-1944
Practice Address - Fax:913-588-2496
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-21418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100230190AMedicaid
080082410OtherRAILROAD MEDICARE
MS13319051OtherBCBS KANSAS CITY
MO248633604Medicaid
KS626870OtherFIRSTGUARD
2296860AMedicare ID - Type Unspecified
KS100230190AMedicaid