Provider Demographics
NPI:1104354794
Name:BLUE VALLEY DERMATOLOGY LLC
Entity type:Organization
Organization Name:BLUE VALLEY DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:TKACHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-802-1310
Mailing Address - Street 1:7840 W 165TH STREET
Mailing Address - Street 2:SUITE 260
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223
Mailing Address - Country:US
Mailing Address - Phone:415-802-1310
Mailing Address - Fax:
Practice Address - Street 1:7840 W 165TH STREET
Practice Address - Street 2:SUITE 260
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223
Practice Address - Country:US
Practice Address - Phone:415-802-1310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-26
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-36968207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty