Provider Demographics
NPI:1942356977
Name:MID AMERICA SENIOR MANAGEMENT LLC
Entity Type:Organization
Organization Name:MID AMERICA SENIOR MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MATHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-742-4084
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:TONGANOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:66086-0996
Mailing Address - Country:US
Mailing Address - Phone:913-742-4084
Mailing Address - Fax:913-742-4086
Practice Address - Street 1:21107 DONAHOO RD
Practice Address - Street 2:
Practice Address - City:TONGANOXIE
Practice Address - State:KS
Practice Address - Zip Code:66086-4153
Practice Address - Country:US
Practice Address - Phone:913-742-4084
Practice Address - Fax:913-742-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21601207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100347530AMedicaid
MOMA3349Medicare PIN
KS100347530AMedicaid
MOMA3350Medicare PIN