1669585766 NPI number — HEARTLAND PHYSICIAN SERVICES, LLC

Table of content: (NPI 1669585766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669585766 NPI number — HEARTLAND PHYSICIAN SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND PHYSICIAN SERVICES, 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:
KANSAS CITY FAMILY MEDICAL CARE
Provider Other Organization Name Type Code:
3
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:
1669585766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 CARONDELET DR
Provider Second Line Business Mailing Address:
STE 300A
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64114-4801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-941-9030
Provider Business Mailing Address Fax Number:
816-941-3866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1004 CARONDELET DR
Provider Second Line Business Practice Location Address:
STE 300A
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64114-4801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-941-9030
Provider Business Practice Location Address Fax Number:
816-941-3866
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GAVIN
Authorized Official First Name:
PAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
816-941-9030

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  101923 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MA4728 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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