Basic Information
| Provider Information | |||||||||
| NPI: | 1912191271 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BDC KANSAS CITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3001 6TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | GREAT LAKES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600882833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476884560 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3001 6TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | GREAT LAKES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600882833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476884560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 08/30/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRIEPENTROG | ||||||||
| AuthorizedOfficialFirstName: | DUWAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMPTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 8476882888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
No ID Information.