1134310154 NPI number — OTHMER PSYCHIATRIC CENTER

Table of content: (NPI 1134310154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134310154 NPI number — OTHMER PSYCHIATRIC CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTHMER PSYCHIATRIC CENTER
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:
PICTURE HILLS PSYCHIATRIC CENTER
Provider Other Organization Name Type Code:
5
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:
1134310154
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5709 NW 64TH TER
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:
64151-2382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-746-5555
Provider Business Mailing Address Fax Number:
816-746-5996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5709 NW 64TH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64151-2382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-746-5555
Provider Business Practice Location Address Fax Number:
816-746-5996
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OTHMER
Authorized Official First Name:
SIEGLINDE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
816-746-5555

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1473 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 003750 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 2005021811 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 33862 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364S00000X , with the licence number: 2005027490 , 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: 2005021811 . This is a "STATE OF MO MD LICENSE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 497729418 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202302113 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD-063-511L . This is a "CHILD AND ADOLESCENT PSYC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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