Basic Information
| Provider Information | |||||||||
| NPI: | 1265072706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHLANDS BREAST CARE & THERAPY CENTER | ||||||||
| 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: | |||||||||
| Practice Location | |||||||||
| Address1: | 6069 S SOUTHLANDS PKWY | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800165316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037157000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2020 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEARY | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3036431022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PORTERCARE ADVENTIST HEALTH SYSTEM | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.