Provider Demographics
NPI:1104048933
Name:BOERSMA, MELISA G (MD)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:G
Last Name:BOERSMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 N GREEN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154-1910
Mailing Address - Country:US
Mailing Address - Phone:913-574-2520
Mailing Address - Fax:913-574-2520
Practice Address - Street 1:8700 N GREEN HILLS RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154
Practice Address - Country:US
Practice Address - Phone:913-574-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190332112085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123050AMedicaid
OKOKAAA3662Medicare PIN