Provider Demographics
NPI:1700870516
Name:ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS LLC
Entity Type:Organization
Organization Name:ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS LLC
Other - Org Name:ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS CHTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-319-7534
Mailing Address - Street 1:3651 COLLEGE BLVD
Mailing Address - Street 2:100B
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1904
Mailing Address - Country:US
Mailing Address - Phone:913-362-0031
Mailing Address - Fax:913-319-7662
Practice Address - Street 1:3651 COLLEGE BLVD
Practice Address - Street 2:100B
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1904
Practice Address - Country:US
Practice Address - Phone:913-362-0031
Practice Address - Fax:913-319-7662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0936680002Medicare NSC
KSC490000Medicare ID - Type Unspecified