Provider Demographics
NPI:1346235272
Name:IRICK, CONSTANCE M (MD)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:M
Last Name:IRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15270 W 119TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-5604
Mailing Address - Country:US
Mailing Address - Phone:913-829-8833
Mailing Address - Fax:913-768-4827
Practice Address - Street 1:15270 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-5604
Practice Address - Country:US
Practice Address - Phone:913-829-8833
Practice Address - Fax:913-768-4827
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-22030207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
13429045OtherBCBSKC
13429045OtherBCBSKC
D056946Medicare ID - Type Unspecified
C51897Medicare UPIN