Individual
BRAD A. MOUSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1101 NW PAMELA BLVD, SUITE A, GRAIN VALLEY, MO 64029-7841
(816) 295-1606
(816) 295-1606
Mailing address
1101 NW PAMELA BLVD, SUITE A, GRAIN VALLEY, MO 64029-7841
(816) 295-1606
(816) 295-1606
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
R9G82
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080148316
RR MEDICARE
MO
01
—
13384041
BCBS PROVIDER NUMBER
—
05
—
1588604979
—
MO
01
—
18960020
CFU BCBS
—
01
—
2057742
AETNA
—
01
—
481159444
TAX ID
—
Enumeration date
06/07/2006
Last updated
03/30/2015
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