Basic Information
Provider Information | |||||||||
NPI: | 1841448750 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONCENTRA HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5080 SPECTRUM DRIVE | ||||||||
Address2: | SUITE 1200 WEST TOWER | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 75001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002323550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 12220 A S BLUERIDGE BLVD. | ||||||||
Address2: |   | ||||||||
City: | GRAND VIEW | ||||||||
State: | MO | ||||||||
PostalCode: | 64030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8167631755 | ||||||||
FaxNumber: | 8167631855 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/04/2008 | ||||||||
LastUpdateDate: | 02/18/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEWTON | ||||||||
AuthorizedOfficialFirstName: | KEITH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
AuthorizedOfficialTelephone: | 9723648106 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.