Basic Information
| Provider Information | |||||||||
| NPI: | 1750459657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANSAS UNIVERSITY PHYSICIANS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KU ANESTHESIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 RAINBOW BLVD | ||||||||
| Address2: | 4070 DELP MAIL STOP 4017 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661607415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2467 KU HOSPITAL | ||||||||
| Address2: | MAIL STOP 1034 3901 RAINBOW BLVD | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661607415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | ORNDOFF | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPARTMENT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9135883305 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KANSAS UNIVERSITY PHYSICIANS INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 076631 | 01 | KS | BCBS KS GROUP NUMBER | OTHER | CC8801 | 01 | RR MEDICARE GROUP NUMBER | OTHER | 1094420001 | 01 | DMERC PROVIDER NUMBER | OTHER | 100217430G | 05 | KS | MEDICAID | 542174701 | 05 | MO | MEDICAID | 09364025 | 01 | MO | BCBS KC GROUP NUMBER | OTHER |