1679555262 NPI number — LEAVENWORTH ANESTHESIA PA

Table of content: (NPI 1679555262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679555262 NPI number — LEAVENWORTH ANESTHESIA PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEAVENWORTH ANESTHESIA 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:
6
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:
1679555262
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 SHAWNEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEAVENWORTH
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66048-1958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-680-0812
Provider Business Mailing Address Fax Number:
913-680-1445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 SHAWNEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-1958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-680-0812
Provider Business Practice Location Address Fax Number:
913-680-1445
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COVILLO
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
913-680-0812

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10811021 . This is a "BCBS KANSAS CITY" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: CI9911 . This is a "RR MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 10811021 . This is a "PREFERRED HEALTH PROFESSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: C19910 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: DC6685 . This is a "RR MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 004640 . This is a "BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: CD7473 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: DC6685 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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