Provider Demographics
NPI:1205802741
Name:TOLENTINO, ADDISON RACOMA (MD)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:RACOMA
Last Name:TOLENTINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E. 104TH ST
Mailing Address - Street 2:MAILSTOP 400N
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-8752
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:4321 WASHINGTON ST STE 4000
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-5965
Practice Address - Country:US
Practice Address - Phone:816-932-3300
Practice Address - Fax:816-932-5793
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015015966207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14477Medicare PIN
SDH37034Medicare UPIN
SDS100067Medicare PIN
SD407191042884OtherPREFERRED ONE
SD2201943OtherARAZ/ AMERICA'S PPO
MN939651900Medicaid
SD57105V006OtherWPS TRICARE
SD5506OtherDAKOTACARE
SDHP47808OtherHEALTHPARTNERS
SD36794OtherSANFORD HEALTH PLAN
NE46022474336Medicaid
IA38193/38194OtherBLUE CROSS
SD3600520OtherMEDICA
SDH37034Medicare UPIN
SD6631110Medicaid
SDS100067Medicare PIN
SDP00221912OtherRR MEDICARE
IA0588707Medicaid
MN599R7TOOtherBLUE CROSS
SD231131OtherMIDLANDS CHOICE