Provider Demographics
NPI: | 1356683213 |
---|---|
Name: | PRIME HEALTHCARE PHYSICIAN SERVICES - PROVIDENCE INC |
Entity Type: | Organization |
Organization Name: | PRIME HEALTHCARE PHYSICIAN SERVICES - PROVIDENCE INC |
Other - Org Name: | PROVIDENCE MEDICAL GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | MANAGING ASSOCIATE GENERAL COUNSEL |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CHRISTOPHER |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DOAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 310-259-4706 |
Mailing Address - Street 1: | 8929 PARALLEL PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | KANSAS CITY |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 66112-1689 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 913-596-3930 |
Mailing Address - Fax: | 913-596-4098 |
Practice Address - Street 1: | 16663 MIDLAND DR STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | SHAWNEE |
Practice Address - State: | KS |
Practice Address - Zip Code: | 66217-3042 |
Practice Address - Country: | US |
Practice Address - Phone: | 913-631-2600 |
Practice Address - Fax: | 913-631-2606 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | PRIME HEALTHCARE SERVICES, INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2013-03-19 |
Last Update Date: | 2023-08-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
No | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Multi-Specialty | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | Group - Multi-Specialty |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207VF0040X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 2083P0011X | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | Group - Multi-Specialty |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0120X | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 201193920H | Medicaid | |
MO | 500017218 | Medicaid |