Provider Demographics
NPI:1720183346
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:PHYSICIAN CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STAPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-903-8880
Mailing Address - Street 1:301 S PLATTE CLAY WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-8214
Mailing Address - Country:US
Mailing Address - Phone:816-903-8880
Mailing Address - Fax:816-903-8884
Practice Address - Street 1:301 S PLATTE CLAY WAY
Practice Address - Street 2:SUITE B
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8214
Practice Address - Country:US
Practice Address - Phone:816-903-8880
Practice Address - Fax:816-903-8884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
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
MON230000Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER