Provider Demographics
NPI:1629517107
Name:COCKERELL & MCINTOSH PEDIATRICS, PC
Entity Type:Organization
Organization Name:COCKERELL & MCINTOSH PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-228-4770
Mailing Address - Street 1:205 NW R D MIZE RD
Mailing Address - Street 2:STE 304
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2515
Mailing Address - Country:US
Mailing Address - Phone:816-228-4770
Mailing Address - Fax:816-228-1156
Practice Address - Street 1:205 NW R D MIZE RD
Practice Address - Street 2:STE 304
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2515
Practice Address - Country:US
Practice Address - Phone:816-228-4770
Practice Address - Fax:816-228-1156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016036885363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty