Provider Demographics
NPI:1437308889
Name:RADIOLOGY ASSOCIATES OF KANSAS CITY, LLC
Entity Type:Organization
Organization Name:RADIOLOGY ASSOCIATES OF KANSAS CITY, LLC
Other - Org Name:SKIN DEEP LASER & VEIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:IDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-599-6777
Mailing Address - Street 1:9212 NIEMAN RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1868
Mailing Address - Country:US
Mailing Address - Phone:913-599-6777
Mailing Address - Fax:913-599-3955
Practice Address - Street 1:4809 W 117TH ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-2051
Practice Address - Country:US
Practice Address - Phone:913-327-8702
Practice Address - Fax:913-327-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA1377Medicare PIN