Provider Demographics
NPI:1598885295
Name:BOULEVARD DERMATOLOGY P A
Entity Type:Organization
Organization Name:BOULEVARD DERMATOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-318-9400
Mailing Address - Street 1:5520 COLLEGE BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1630
Mailing Address - Country:US
Mailing Address - Phone:913-451-5934
Mailing Address - Fax:913-451-4716
Practice Address - Street 1:5520 COLLEGE BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1630
Practice Address - Country:US
Practice Address - Phone:913-451-5934
Practice Address - Fax:913-451-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSX970000Medicare PIN