Provider Demographics
NPI:1053480897
Name:COLORECTAL SURGERY PA
Entity Type:Organization
Organization Name:COLORECTAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CARMEN
Authorized Official - Last Name:CIROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-831-1900
Mailing Address - Street 1:8901 W 74TH ST
Mailing Address - Street 2:#148
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204
Mailing Address - Country:US
Mailing Address - Phone:913-831-1900
Mailing Address - Fax:913-831-1999
Practice Address - Street 1:8901 W 74TH ST
Practice Address - Street 2:#148
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:913-831-1900
Practice Address - Fax:913-831-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0424933208C00000X
MO105102208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0007494AMedicaid
KS0007494AMedicaid
E89297Medicare UPIN