Provider Demographics
NPI:1710056502
Name:SHOAL CREEK FAMILY MEDICINE AND ALLERGY, PC
Entity Type:Organization
Organization Name:SHOAL CREEK FAMILY MEDICINE AND ALLERGY, PC
Other - Org Name:STAPLETON FAMILY HEALTH CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:STAPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-781-4244
Mailing Address - Street 1:9784 N ASH AVENUE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64157
Mailing Address - Country:US
Mailing Address - Phone:816-781-4244
Mailing Address - Fax:816-781-3542
Practice Address - Street 1:9784 N ASH AVENUE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64157
Practice Address - Country:US
Practice Address - Phone:816-781-4244
Practice Address - Fax:816-781-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO32015013OtherBCBS GROUP NUMBER
MO32015013OtherBCBS GROUP NUMBER