Provider Demographics
NPI:1578673281
Name:INBORIBOON, PHOLAPHAT CHARLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHOLAPHAT
Middle Name:CHARLIE
Last Name:INBORIBOON
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 1:2310 HOLMES ST
Mailing Address - Street 2:STE 800
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2602
Mailing Address - Country:US
Mailing Address - Phone:816-218-2500
Mailing Address - Fax:
Practice Address - Street 1:2301 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2640
Practice Address - Country:US
Practice Address - Phone:816-404-1536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239506207P00000X
MO2012013852207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02775895Medicaid
NY02775895Medicaid
NYI69209Medicare UPIN