Provider Demographics
NPI:1881803229
Name:COLLEGE PARK FAMILY CARE CENTER, P.A.
Entity type:Organization
Organization Name:COLLEGE PARK FAMILY CARE CENTER, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-469-0503
Mailing Address - Street 1:11755 W 112TH ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2761
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:913-338-1311
Practice Address - Street 1:11755 W 112TH ST
Practice Address - Street 2:STE. 101
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2761
Practice Address - Country:US
Practice Address - Phone:913-469-0503
Practice Address - Fax:913-338-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0484665OtherAETNA
KS5696741OtherAETNA