Provider Demographics
NPI:1952947939
Name:PROVIDENCE MEDICAL GROUP
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF OFFICE
Authorized Official - Prefix:MS
Authorized Official - First Name:DIEDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:913-596-4000
Mailing Address - Street 1:8919 PARALLEL PKWY STE 555
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-3628
Mailing Address - Country:US
Mailing Address - Phone:913-596-3930
Mailing Address - Fax:
Practice Address - Street 1:8919 PARALLEL PKWY STE 555
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-3628
Practice Address - Country:US
Practice Address - Phone:913-596-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1598741472OtherNPI