Basic Information
Provider Information | |||||||||
NPI: | 1679837249 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SERC REHABILITATION PARTNERS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SERC - HARRISONVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8823 PRODUCTION LN | ||||||||
Address2: |   | ||||||||
City: | OOLTEWAH | ||||||||
State: | TN | ||||||||
PostalCode: | 373636511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232387217 | ||||||||
FaxNumber: | 4232383473 | ||||||||
Practice Location | |||||||||
Address1: | 678 S COMMERCIAL ST | ||||||||
Address2: |   | ||||||||
City: | HARRISONVILLE | ||||||||
State: | MO | ||||||||
PostalCode: | 64701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8163803325 | ||||||||
FaxNumber: | 8163803044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2012 | ||||||||
LastUpdateDate: | 02/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHANNESON | ||||||||
AuthorizedOfficialFirstName: | KEVIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 4232387217 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QX0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | MA4370 | 01 | MO | GROUP MEDICARE PTAN | OTHER |