Provider Demographics
NPI:1750374724
Name:BOYACK, DARREN AMUNDSEN
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:AMUNDSEN
Last Name:BOYACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 W 74TH ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-4004
Mailing Address - Country:US
Mailing Address - Phone:913-676-2214
Mailing Address - Fax:913-789-3106
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-676-2214
Practice Address - Fax:913-789-3106
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431179207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200346760BMedicaid
P00263567OtherRR MEDICARE GROUP CG8899
01674018OtherBCBS KCMO GROUP 01674018
MO207449406Medicaid
KS200346760AMedicaid
35924016OtherBCBS OF KC MO
KS35924036OtherBCBS KCMO GROUP 01674018
P00291773OtherRR MEDICARE GROUP DC6712
KS763E122Medicare PIN
35924016OtherBCBS OF KC MO
P00263567OtherRR MEDICARE GROUP CG8899