Provider Demographics
NPI:1588604979
Name:MOUSE, BRAD A (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:A
Last Name:MOUSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1101 NW PAMELA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-7841
Mailing Address - Country:US
Mailing Address - Phone:816-295-1606
Mailing Address - Fax:816-295-1606
Practice Address - Street 1:1101 NW PAMELA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-7841
Practice Address - Country:US
Practice Address - Phone:816-295-1606
Practice Address - Fax:816-295-1606
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR9G82207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
18960020OtherCFU BCBS
13384041OtherBCBS PROVIDER NUMBER
MO080148316OtherRR MEDICARE
481159444OtherTAX ID
2057742OtherAETNA
MO1588604979Medicaid
18960020OtherCFU BCBS
MOP00746232Medicare PIN
C51943Medicare UPIN
MOP00746232Medicare UPIN
MOJ616923Medicare PIN