Provider Demographics
NPI:1639287824
Name:SAMUEL O FADARE, MD, PA
Entity Type:Organization
Organization Name:SAMUEL O FADARE, MD, PA
Other - Org Name:SAMUEL O FADARE, MD, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:FADARE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:816-225-6735
Mailing Address - Street 1:1513 UNION AVE STE 2500
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-9412
Mailing Address - Country:US
Mailing Address - Phone:660-372-1313
Mailing Address - Fax:660-372-1339
Practice Address - Street 1:5604 NE ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64119-2327
Practice Address - Country:US
Practice Address - Phone:660-372-1313
Practice Address - Fax:660-372-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X, 106H00000X, 363LP0808X
MO1039392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34160016OtherBLUE SHIELD KANSAS CITY
KS100430330AMedicaid
MO506052208Medicaid
KS100430330BMedicaid
MO34160016OtherBLUE SHIELD KANSAS CITY
KS100430330BMedicaid
MON220000Medicare PIN
KS100430330AMedicaid