Provider Demographics
NPI:1710991252
Name:WORTHAM, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:WORTHAM
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 1:8550 MARSHALL DR
Mailing Address - Street 2:SUITE 220 ADMINISTRATION
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1505
Mailing Address - Country:US
Mailing Address - Phone:913-495-2000
Mailing Address - Fax:913-495-3742
Practice Address - Street 1:4811 S ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6981
Practice Address - Country:US
Practice Address - Phone:816-356-5000
Practice Address - Fax:913-495-3742
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORGB27207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOK674761Medicare PIN
C51664Medicare UPIN
MO110232676Medicare PIN