Basic Information
| Provider Information | |||||||||
| NPI: | 1609084540 | ||||||||
| EntityType: | 2 | ||||||||
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| 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: | 9132531703 | ||||||||
| Practice Location | |||||||||
| Address1: | 3651 COLLEGE BLVD | ||||||||
| Address2: | |||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133197600 | ||||||||
| FaxNumber: | 9132531703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | HANNA | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9132538844 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.