Basic Information
| Provider Information | |||||||||
| NPI: | 1528025053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAYHAWK PRIMARY CARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KU MEDWEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 SHAWNEE MISSION PKWY | ||||||||
| Address2: | MEDICAL ADMINISTRATIVE SERVICES OF KU MED. STE. 312 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889000 | ||||||||
| FaxNumber: | 9135889822 | ||||||||
| Practice Location | |||||||||
| Address1: | 7405 RENNER RD | ||||||||
| Address2: | KU MEDWEST | ||||||||
| City: | SHAWNEE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662179414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135888400 | ||||||||
| FaxNumber: | 9135888413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9139455603 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JAYHAWK PRIMARY CARE INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 25562019 | 01 | BCBS GROUP NUMBER | OTHER | 100217070C | 05 | KS | MEDICAID |