1629078043 NPI number — NOVAMED EYE SURGERY CENTER OF OVERLAND PARK, LLC

Table of content: (NPI 1629078043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629078043 NPI number — NOVAMED EYE SURGERY CENTER OF OVERLAND PARK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVAMED EYE SURGERY CENTER OF OVERLAND PARK, 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:
OVERLAND PARK SURGERY CENTER
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:
1629078043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5520 COLLEGE BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-491-3040
Provider Business Mailing Address Fax Number:
913-491-3640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5520 COLLEGE BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66211-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-491-3040
Provider Business Practice Location Address Fax Number:
913-491-3640
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BALDOCK
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
BOYD
Authorized Official Title or Position:
OFFICER AND AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-234-5900

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  S-046-005 , 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: 490003071 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100279090A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 508157302 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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