Provider Demographics
NPI:1013952886
Name:EVANS PEDIATRIC CLINIC PC
Entity Type:Organization
Organization Name:EVANS PEDIATRIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-351-6385
Mailing Address - Street 1:3912 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3648
Mailing Address - Country:US
Mailing Address - Phone:816-233-5959
Mailing Address - Fax:816-233-5960
Practice Address - Street 1:3912 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3648
Practice Address - Country:US
Practice Address - Phone:816-233-5959
Practice Address - Fax:816-233-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110143208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E78875Medicare UPIN