Basic Information
| Provider Information | |||||||||
| NPI: | 1336269570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC & SPORTS MEDICINE CLINIC OF KANSAS CITY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOPAEDIC & SPORTS MEDICINE CLINIC OF KANSAS CITY, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3651 COLLEGE BLVD | ||||||||
| Address2: | #100A | ||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133197546 | ||||||||
| FaxNumber: | 9133197691 | ||||||||
| Practice Location | |||||||||
| Address1: | 3651 COLLEGE BLVD | ||||||||
| Address2: | #100A | ||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133197546 | ||||||||
| FaxNumber: | 9133197691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWNE | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9133197546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 0416972 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 504394 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 17283059 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 497571 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 06545035 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 14161075 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 76769 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |