Provider Demographics
NPI:1063411916
Name:HAILEY, BRETT R
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:R
Last Name:HAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2747
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66201-2747
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-676-2214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD115613207PE0004X
MO115613207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS27361069OtherBCBS OF KC MO GROUP 01674018 SMMC EMERGENCY PHYSICIANS
KSP00651782OtherRR MEDICARE GROUP CG8899
27361039OtherBLUE CROSS BLUE SHIELD
KS100403970CMedicaid
KSP00721307OtherRR MEDICARE GROUP DC6712
KS100403970AMedicaid
KS100403970BMedicaid
MO204743017Medicaid
KS27361059OtherBCBS OF KC MO GROUP # 30492021 ER PHYSICIANS SOUTH PA
KSP00651782OtherRR MEDICARE GROUP CG8899
KS27361059OtherBCBS OF KC MO GROUP # 30492021 ER PHYSICIANS SOUTH PA
MO204743017Medicaid
KSR97000003Medicare PIN