1265523179 NPI number — DR. STEPHEN C GRADWOHL D.C.

Table of content: (NPI 1275601171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265523179 NPI number — DR. STEPHEN C GRADWOHL D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRADWOHL
Provider First Name:
STEPHEN
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

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:
1265523179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18850 W 96TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENEXA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66220-9702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-768-8229
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11791 W 112TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
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:
913-888-3338
Provider Business Practice Location Address Fax Number:
913-696-1908
Provider Enumeration Date:
09/27/2006

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: 111NX0800X , with the licence number:  01-03761 , 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: 12139018 . This is a "BC/BS K.C." identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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