1750374724 NPI number — DARREN AMUNDSEN BOYACK

Table of content: DARREN AMUNDSEN BOYACK (NPI 1750374724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750374724 NPI number — DARREN AMUNDSEN BOYACK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYACK
Provider First Name:
DARREN
Provider Middle Name:
AMUNDSEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1750374724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9100 W 74TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE MISSION
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66204-4004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-676-2214
Provider Business Mailing Address Fax Number:
913-789-3106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9100 W 74TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWNEE MISSION
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66204-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-676-2214
Provider Business Practice Location Address Fax Number:
913-789-3106
Provider Enumeration Date:
08/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  0431179 , 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: 200346760B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00263567 . This is a "RR MEDICARE GROUP CG8899" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01674018 . This is a "BCBS KCMO GROUP 01674018" identifier . This identifiers is of the category "OTHER".
  • Identifier: 207449406 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200346760A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35924016 . This is a "BCBS OF KC MO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35924036 . This is a "BCBS KCMO GROUP 01674018" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: P00291773 . This is a "RR MEDICARE GROUP DC6712" identifier . This identifiers is of the category "OTHER".




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