1154185601 NPI number — EVERLY PROVIDER GROUP KS, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154185601 NPI number — EVERLY PROVIDER GROUP KS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERLY PROVIDER GROUP KS, 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:
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:
1154185601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
823 CONGRESS AVE STE 1200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78701-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 CONGRESS AVE STE 1200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78701-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-422-3855
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2024

Additional Information

Authorized Official

Authorized Official Last Name:
JOLLY
Authorized Official First Name:
BRANTLEY
Authorized Official Middle Name:
TILLMAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
855-422-3855

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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