Provider Demographics
NPI:1881610913
Name:BARDO, MICHAELENE (DO)
Entity type:Individual
Prefix:
First Name:MICHAELENE
Middle Name:
Last Name:BARDO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-7086
Mailing Address - Fax:
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-7086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015267207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00325865OtherRR MEDICARE
MO2006015267OtherSTATE LICENSE
KS200403050AMedicaid
MO201434701Medicaid
MO201434701Medicaid