Provider Demographics
NPI:1588639025
Name:BRIDGES, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BRIDGES
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 1:3906 OAKLAND AVE, BOX 8252
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64508-7515
Mailing Address - Country:US
Mailing Address - Phone:816-271-7648
Mailing Address - Fax:
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-6575
Practice Address - Fax:816-271-6139
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1021822085R0202X
KS04279392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO300138251OtherRR MEDICARE GROUP CK7871
MO24064048OtherBCBS OF KC MO
KS106183OtherBCBS KS FOR KS LOCATION
MO203612924Medicaid
KS100287240BMedicaid
470767OtherBCBS KS FOR MO LOCATION
KS106183OtherBCBS KS FOR KS LOCATION
KS100287240BMedicaid
MOE60290Medicare UPIN