Provider Demographics
NPI:1477596484
Name:TOWN PLAZA FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:TOWN PLAZA FAMILY PRACTICE, LLC
Other - Org Name:NORTHRIDGE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-254-0918
Mailing Address - Street 1:15270 W 119TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-5604
Mailing Address - Country:US
Mailing Address - Phone:913-254-0828
Mailing Address - Fax:
Practice Address - Street 1:15270 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-5604
Practice Address - Country:US
Practice Address - Phone:913-254-0828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS20-877559-01Medicaid
MO11372027OtherBLUE COSS/BLUE SHIELD OF
KS20-877559-01Medicaid