Provider Demographics
NPI:1679881767
Name:PEDIATRIC HEADACHE CENTER PC
Entity type:Organization
Organization Name:PEDIATRIC HEADACHE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-509-3363
Mailing Address - Street 1:400 E RED BRIDGE RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4035
Mailing Address - Country:US
Mailing Address - Phone:816-509-3363
Mailing Address - Fax:
Practice Address - Street 1:400 E RED BRIDGE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-4035
Practice Address - Country:US
Practice Address - Phone:816-509-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105950208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty