Provider Demographics
NPI:1396844874
Name:SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SOUTHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:620-231-5855
Mailing Address - Street 1:107 N PINE
Mailing Address - Street 2:STE 1
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-231-5855
Mailing Address - Fax:
Practice Address - Street 1:107 N PINE
Practice Address - Street 2:STE 1
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-231-5855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02934225100000X
KS24-00361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200421170AMedicaid
KS115683OtherBCBS GROUP
KS1156683Medicare ID - Type UnspecifiedMEDICARE
KSDF3967Medicare ID - Type UnspecifiedMEDICARE