1760486674 NPI number — DR. SUSAN K BONAR M.D.

Table of content: SAMANTHA DEITERING (NPI 1306225438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760486674 NPI number — DR. SUSAN K BONAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONAR
Provider First Name:
SUSAN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1760486674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11237 NALL AVE STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEAWOOD
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211-1655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-469-3690
Provider Business Mailing Address Fax Number:
913-469-3692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11237 NALL AVE STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAWOOD
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66211-1655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-469-3690
Provider Business Practice Location Address Fax Number:
913-469-3692
Provider Enumeration Date:
06/08/2005

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: 207XX0004X , with the licence number:  04-29549 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0004X , with the licence number: 0429549 , 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: 202879427 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21386021 . This is a "BCBS OF KC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 202879427 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 5778210 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 202879727 . This is a "GREAT WEST HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 202879427 . This is a "COVENTRY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 202879427 . This is a "ADVANTRA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 207754219 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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