Provider Demographics
NPI:1194000570
Name:PHOENIX HEALTHCARE CLINIC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:913-549-8197
Mailing Address - Street 1:11960 QUIVIRA ROAD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213
Mailing Address - Country:US
Mailing Address - Phone:913-851-0500
Mailing Address - Fax:913-851-0502
Practice Address - Street 1:11960 QUIVIRA ROAD
Practice Address - Street 2:SUITE #100
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213
Practice Address - Country:US
Practice Address - Phone:913-851-0500
Practice Address - Fax:913-851-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100344690DMedicaid
MO1275868622Medicaid
KS200530820AMedicaid
MO1174628994Medicaid
KSKA1270003Medicare PIN
MO1275868622Medicaid
KS200530820AMedicaid
MOP22701Medicare UPIN
MO1174628994Medicaid