Provider Demographics
NPI:1598716243
Name:TIEVES, KELLY S (DO)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:S
Last Name:TIEVES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 GILLHAM RD
Mailing Address - Street 2:CHILDREN'S MERCY HOSPITAL
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-234-3041
Mailing Address - Fax:
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:CHILDREN'S MERCY HOSPITAL
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-234-3041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060344912080P0203X
KS05-322282080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32542500Medicaid
004000215JOtherHUMANA
G91349Medicare UPIN