Basic Information
Provider Information | |||||||||
NPI: | 1417499708 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OVERLAND PARK ORTHOPEDICS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OVERLAND PARK SURGICAL SPECIALISTS & SPORTS MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12200 W 106TH ST | ||||||||
Address2: | STE 400 | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662152305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9135415500 | ||||||||
FaxNumber: | 9135417474 | ||||||||
Practice Location | |||||||||
Address1: | 12200 W 106TH ST | ||||||||
Address2: | STE. 400 | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662152305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9135415500 | ||||||||
FaxNumber: | 9135417474 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2016 | ||||||||
LastUpdateDate: | 11/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LINDSAY | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 9135415500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 15-01079 | KS | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.