1861415846 NPI number — COLLEGE PARK FAMILY CARE CENTER, P.A.

Table of content: (NPI 1861415846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861415846 NPI number — COLLEGE PARK FAMILY CARE CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLEGE PARK FAMILY CARE CENTER, P.A.
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:
AMBULATORY SURGICAL 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:
1861415846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11725 W 112TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66210-2761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-469-5579
Provider Business Mailing Address Fax Number:
913-338-1311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11725 W 112TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66210-2761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-469-5579
Provider Business Practice Location Address Fax Number:
913-338-1311
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
O.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
913-469-0503

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  S-046-007 , 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: 8500019 . This is a "MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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