Basic Information
| Provider Information | |||||||||
| NPI: | 1598970790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAWNEE MISSION MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SMMC EMERGENCY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15980 COLLECTION CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606930159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341350 | ||||||||
| FaxNumber: | 9132341108 | ||||||||
| Practice Location | |||||||||
| Address1: | 9100 W 74TH ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136762214 | ||||||||
| FaxNumber: | 9137893106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 02/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | SAMUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9132341350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHAWNEE MISSION MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 100007000A | 05 | KS | MEDICAID | 507414308 | 05 | MO | MEDICAID |