Basic Information
| Provider Information | |||||||||
| NPI: | 1598498271 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DICKSON DIVELEY MIDWEST ORTHOPAEDIC CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3651 COLLEGE BLVD | ||||||||
| Address2: | |||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133197600 | ||||||||
| FaxNumber: | 9132531702 | ||||||||
| Practice Location | |||||||||
| Address1: | 7450 W FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662034670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133197600 | ||||||||
| FaxNumber: | 9132531765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2022 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | DIVELBISS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9133197600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.