Provider Demographics
NPI:1124087861
Name:MID-AMERICA POLYCLINIC PA
Entity type:Organization
Organization Name:MID-AMERICA POLYCLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NALAMACHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-599-2440
Mailing Address - Street 1:7100 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210
Mailing Address - Country:US
Mailing Address - Phone:913-599-2440
Mailing Address - Fax:913-599-5252
Practice Address - Street 1:7100 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210
Practice Address - Country:US
Practice Address - Phone:913-599-2440
Practice Address - Fax:913-599-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO21532015OtherBLUE SHIELD KANSAS CITY
MO21532015OtherBLUE SHIELD KANSAS CITY
CC7869Medicare PIN