1376691444 NPI number — MID-AMERICA UROLOGY, PA

Table of content: (NPI 1376691444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376691444 NPI number — MID-AMERICA UROLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-AMERICA UROLOGY, PA
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:
1376691444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20375 W 151ST ST
Provider Second Line Business Mailing Address:
STE 270
Provider Business Mailing Address City Name:
OLATHE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66061-5306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-780-3388
Provider Business Mailing Address Fax Number:
913-780-3256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 BAPTISTE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAOLA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66071-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-780-3388
Provider Business Practice Location Address Fax Number:
913-780-3256
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONNETT
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
913-780-3388

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100153430B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS3061 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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