Provider Demographics
NPI:1619971082
Name:KU MEDWEST AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:KU MEDWEST AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRANTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MBA
Authorized Official - Phone:913-588-8403
Mailing Address - Street 1:7405 RENNER RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66217-9414
Mailing Address - Country:US
Mailing Address - Phone:913-588-8411
Mailing Address - Fax:913-588-8432
Practice Address - Street 1:7405 RENNER RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66217-9414
Practice Address - Country:US
Practice Address - Phone:913-588-8411
Practice Address - Fax:913-588-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSS-046-011261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100458080AMedicaid
KS100458080AMedicaid