Provider Demographics
NPI:1316969884
Name:KANSAS CITY INTERNAL MEDICINE PA
Entity type:Organization
Organization Name:KANSAS CITY INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, FACMPE
Authorized Official - Phone:913-319-7303
Mailing Address - Street 1:12140 NALL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2504
Mailing Address - Country:US
Mailing Address - Phone:913-451-8500
Mailing Address - Fax:913-451-1754
Practice Address - Street 1:12140 NALL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2504
Practice Address - Country:US
Practice Address - Phone:913-451-8500
Practice Address - Fax:913-451-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111706207R00000X
MO103093207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200305470Medicaid
MO506936400Medicaid
KS200305470Medicaid