Basic Information
| Provider Information | |||||||||
| NPI: | 1144211384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KC PAIN CENTERS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8717 W 110TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134282900 | ||||||||
| FaxNumber: | 9134282951 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 NE MISSOURI RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640864722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167631559 | ||||||||
| FaxNumber: | 8169658404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRINDSTAFF | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9134282900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANESTHESIA ASSOCIATES OF KANSAS CITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD, PHD | ||||||||
| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH6776 | 01 | MO | RR MEDICARE KCP | OTHER | CK2816 | 01 | MO | RR MEDICARE | OTHER | 509679106 | 05 | MO | MEDICAID | CR0764 | 01 | MO | RR MEDICARE | OTHER | 18971015 | 01 | MO | BCBS | OTHER | H530000 | 01 | MO | MEDICARE | OTHER |