1396844874 NPI number — SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, LLC

Table of content: (NPI 1396844874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396844874 NPI number — SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, 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:
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:
1396844874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 N PINE
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
PITTSBURG
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-231-5855
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 N PINE
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-231-5855
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RANDALL
Authorized Official First Name:
SOUTHARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
620-231-5855

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  11-02934 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 24-00361 , 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: 200421170A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115683 . This is a "BCBS GROUP" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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