Basic Information
| Provider Information | |||||||||
| NPI: | 1053920538 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | URRK UROLOGY DTC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801106 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009530104 | ||||||||
| FaxNumber: | 3037656670 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 E BELLEVIEW AVE STE 270E | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801112882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036493710 | ||||||||
| FaxNumber: | 3036493711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2020 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | SKINNER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR- OMA | ||||||||
| AuthorizedOfficialTelephone: | 3036717175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.