Basic Information
| Provider Information | |||||||||
| NPI: | 1790742765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAYHAWK PRIMARY CARE INC | ||||||||
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| OtherOrganizationName: | FAMILY CARE OF INDEPENDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2330 SHAWNEE MISSION PKWY | ||||||||
| Address2: | MEDICAL ADMINISTRATIVE SERVICES OF KU MED. STE. 312 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662052005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135889856 | ||||||||
| FaxNumber: | 9135889822 | ||||||||
| Practice Location | |||||||||
| Address1: | 4721 S CLIFF AVE | ||||||||
| Address2: | FAMILY CARE OF INDEPENDENCE SUITE 200 | ||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640557016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165033700 | ||||||||
| FaxNumber: | 8165033704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | MYRTLE | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | HR DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9135889808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JAYHAWK PRIMARY CARE INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21211013 | 01 | BCBS GROUP NUMBER | OTHER |