Provider Demographics
NPI:1235227885
Name:ORTHOPEDIC & SPORTS MEDICINE CENTER LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPORTS MEDICINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SIOUX
Authorized Official - Middle Name:
Authorized Official - Last Name:KEARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-233-9888
Mailing Address - Street 1:3107 FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2911
Mailing Address - Country:US
Mailing Address - Phone:816-233-9888
Mailing Address - Fax:816-233-0414
Practice Address - Street 1:820 RAVENHILL DR
Practice Address - Street 2:ATCHISON COMMUNITY HOSPITAL
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-9268
Practice Address - Country:US
Practice Address - Phone:816-233-9888
Practice Address - Fax:816-233-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-29855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS104290Medicare ID - Type UnspecifiedBAM'S KS MEDICARE #