Basic Information
| Provider Information | |||||||||
| NPI: | 1730621988 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND ORTHOPEDICS & SPORTS MEDICINE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4000 W 6TH ST | ||||||||
| Address2: | STE B #105 | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660493205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854030405 | ||||||||
| FaxNumber: | 7852224504 | ||||||||
| Practice Location | |||||||||
| Address1: | 2790 CLAY EDWARDS DR | ||||||||
| Address2: | STE 1230 | ||||||||
| City: | NORTH KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641163276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162149300 | ||||||||
| FaxNumber: | 8162149330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8168413805 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | MO | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | MO | N | Suppliers | Prosthetic/Orthotic Supplier | 261QM2500X | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.