Basic Information
| Provider Information | |||||||||
| NPI: | 1700870516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS CHTD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3651 COLLEGE BLVD | ||||||||
| Address2: | 100B | ||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133620031 | ||||||||
| FaxNumber: | 9133197662 | ||||||||
| Practice Location | |||||||||
| Address1: | 3651 COLLEGE BLVD | ||||||||
| Address2: | 100B | ||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133620031 | ||||||||
| FaxNumber: | 9133197662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9133197534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.