1730345885 NPI number — OVERLAND PARK SURGICAL SPECIALTIES, LLC

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 1730345885 NPI number — OVERLAND PARK SURGICAL SPECIALTIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OVERLAND PARK SURGICAL SPECIALTIES, 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:
COLLEGE PARK FAMILY CARE CENTER PHYSICIANS GROUP
Provider Other Organization Name Type Code:
3
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:
1730345885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741331
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-1331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-469-0503
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11725 W 112TH ST
Provider Second Line Business Practice Location Address:
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:
913-469-5579
Provider Business Practice Location Address Fax Number:
913-338-1311
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
CHUCK
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
913-469-0503

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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