1114258886 NPI number — AB JETMORE MD LLC

Table of content: (NPI 1114258886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114258886 NPI number — AB JETMORE MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AB JETMORE MD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114258886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7673
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66207-0673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-322-8859
Provider Business Mailing Address Fax Number:
888-778-9471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21106 W 95TH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENEXA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66220-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-322-8859
Provider Business Practice Location Address Fax Number:
888-778-9471
Provider Enumeration Date:
01/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JETMORE
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
913-829-7716

Provider Taxonomy Codes

  • Taxonomy code: 208C00000X , with the licence number:  04-24436 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4221151 . This is a "AETNA" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 42525017 . This is a "BLUE SHIELD KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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