1194745620 NPI number — FACIAL SURGERY GROUP PC

Table of content: (NPI 1194745620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194745620 NPI number — FACIAL SURGERY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FACIAL SURGERY GROUP PC
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:
TANNER AND MOORE
Provider Other Organization Name Type Code:
4
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:
1194745620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 802752
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-561-1115
Provider Business Mailing Address Fax Number:
816-753-4493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4700 BELLEVIEW
Provider Second Line Business Practice Location Address:
STE L 10
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64112-1360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-561-1115
Provider Business Practice Location Address Fax Number:
816-931-7912
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
LOUANN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
816-561-1115

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DE015905 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223S0112X , with the licence number: DE015216 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 27056013 . This is a "BCBS OF KCMO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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