Provider Demographics
NPI:1780797142
Name:COLON AND RECTAL SURGEONS OF KC PA
Entity type:Organization
Organization Name:COLON AND RECTAL SURGEONS OF KC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VIVONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-677-4010
Mailing Address - Street 1:8901 W 74TH ST
Mailing Address - Street 2:SUITE 149
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2204
Mailing Address - Country:US
Mailing Address - Phone:913-677-4010
Mailing Address - Fax:913-677-1164
Practice Address - Street 1:8901 W 74TH ST
Practice Address - Street 2:SUITE 149
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2204
Practice Address - Country:US
Practice Address - Phone:913-677-4010
Practice Address - Fax:913-677-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7G39208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR7G39OtherMISSOURI STATE MED LICENS