Basic Information
| Provider Information | |||||||||
| NPI: | 1700921970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE CARE AN OPERATING DIVISION OF PROVIDENCE MEDICAL CTR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | DEPT CH 14363 | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600554363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852958108 | ||||||||
| FaxNumber: | 7852707646 | ||||||||
| Practice Location | |||||||||
| Address1: | 913 SHEIDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | BONNER SPRINGS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660129514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133227222 | ||||||||
| FaxNumber: | 9133227284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 04/20/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NYP | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9135964000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVIDENCE MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 37765011 | 01 | KS | BCBS KANSAS CITY | OTHER | DF7207 | 01 | KS | RAILROAD MEDICARE | OTHER | 200429440A | 05 | KS | MEDICAID | X150000 | 01 | KS | MEDICARE KANSAS CITY | OTHER |