Basic Information
| Provider Information | |||||||||
| NPI: | 1962450569 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPINE & EXTREMITY REHABILITATION CENTER OF KANSAS CITY NORTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SERC OF KANSAS CITY NORTH; SERC OF METRO NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 220 NW PLATTE VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641509793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165053422 | ||||||||
| FaxNumber: | 8165053312 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 NW PLATTE VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641509793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165053422 | ||||||||
| FaxNumber: | 8165053312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8165053422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 103074 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 27888022 | 01 | MO | BCBS | OTHER |