Provider Demographics
NPI:1609966753
Name:ADULT AND PEDIATRIC DERMATOLOGY
Entity Type:Organization
Organization Name:ADULT AND PEDIATRIC DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-948-9184
Mailing Address - Street 1:4601 W. 109TH STREET
Mailing Address - Street 2:SUITE 116
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1313
Mailing Address - Country:US
Mailing Address - Phone:913-469-1115
Mailing Address - Fax:913-469-9192
Practice Address - Street 1:4601 W 109TH ST STE 116
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1313
Practice Address - Country:US
Practice Address - Phone:913-469-1115
Practice Address - Fax:913-469-9192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0422209207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSCI3423OtherMEDICARE RAILROAD
KSJ410000Medicare PIN