Provider Demographics
NPI:1124609425
Name:ORTHOPEDIC & SPORTS MEDICINE CENTER
Entity type:Organization
Organization Name:ORTHOPEDIC & SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-233-9888
Mailing Address - Street 1:3107 FREDERICK AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3082
Mailing Address - Country:US
Mailing Address - Phone:816-233-9888
Mailing Address - Fax:
Practice Address - Street 1:6301 N LUCERNE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64151-3105
Practice Address - Country:US
Practice Address - Phone:816-569-1802
Practice Address - Fax:816-569-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty