Provider Demographics
NPI:1740306273
Name:SOUTHWELL, JAMES L JR (DO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:SOUTHWELL
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CARONDELET DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4801
Mailing Address - Country:US
Mailing Address - Phone:816-942-4500
Mailing Address - Fax:816-941-4504
Practice Address - Street 1:1004 CARONDELET DR
Practice Address - Street 2:SUITE 410
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4801
Practice Address - Country:US
Practice Address - Phone:816-942-4500
Practice Address - Fax:816-941-4504
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-060532084N0400X
IDO-04652084N0400X
MO20100340702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
44833018OtherBLUE CROSS BLUE SHIELD OF KC
MO1740306273Medicaid
KS200681570AMedicaid
MO1740306273Medicaid
MOMA1922009Medicare PIN