Provider Demographics
NPI:1558321380
Name:JERNSTROM, VANCE R (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:R
Last Name:JERNSTROM
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:PO BOX 504538
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4538
Mailing Address - Country:US
Mailing Address - Phone:816-932-7940
Mailing Address - Fax:816-932-7957
Practice Address - Street 1:5844 NW BARRY RD
Practice Address - Street 2:STE 340
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-1465
Practice Address - Country:US
Practice Address - Phone:816-880-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5C10207Y00000X
NE19023207Y00000X
KS04-21322207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025459400Medicaid
NE34161OtherBCBSN
IA0735977Medicaid
MO1558321380Medicaid
IA1735977Medicaid
NE10025459400Medicaid
IA0735977Medicaid
KSKA1801003Medicare PIN
3906273AMedicare ID - Type Unspecified