Provider Demographics
NPI:1275611444
Name:VEIN CLINIC OF GREATER KANSAS CITY, P.A.
Entity Type:Organization
Organization Name:VEIN CLINIC OF GREATER KANSAS CITY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MNAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DAPHENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROORDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-541-3377
Mailing Address - Street 1:4400 W 109TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1319
Mailing Address - Country:US
Mailing Address - Phone:913-541-3377
Mailing Address - Fax:913-541-8082
Practice Address - Street 1:4400 W 109TH ST STE 150
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1319
Practice Address - Country:US
Practice Address - Phone:913-541-3377
Practice Address - Fax:913-541-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0418701207Q00000X
KS0418958208600000X
2086S0129X
722622471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09280021OtherBLUE CROSS BLUE SHIELD
844398OtherAENTA HMO
KS65228OtherBLUE CROSS BLUE SHIELD
KSKS0418701OtherSTATE LICENSE
434308OtherAETNA PPO
KS09509075OtherBCBS
KS45750OtherSTATE LICENSE ARNP
766289OtherHUMANA
MO08561018OtherBLUE CROSS BLUE SHIELD GR
766289OtherHUMANA
766289OtherHUMANA
KS45750OtherSTATE LICENSE ARNP
MO08561018OtherBLUE CROSS BLUE SHIELD GR
=========OtherTAX ID
KSKS0418701OtherSTATE LICENSE