Provider Demographics
NPI:1700921970
Name:PROVIDENCE CARE AN OPERATING DIVISION OF PROVIDENCE MEDICAL CTR
Entity Type:Organization
Organization Name:PROVIDENCE CARE AN OPERATING DIVISION OF PROVIDENCE MEDICAL CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:NYP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-596-4000
Mailing Address - Street 1:DEPT CH 14363
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-4363
Mailing Address - Country:US
Mailing Address - Phone:785-295-8108
Mailing Address - Fax:785-270-7646
Practice Address - Street 1:913 SHEIDLEY AVE
Practice Address - Street 2:
Practice Address - City:BONNER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66012-9514
Practice Address - Country:US
Practice Address - Phone:913-322-7222
Practice Address - Fax:913-322-7284
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-21
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS37765011OtherBCBS KANSAS CITY
KSDF7207OtherRAILROAD MEDICARE
KS200429440AMedicaid
KSX150000OtherMEDICARE KANSAS CITY
KS37765011OtherBCBS KANSAS CITY