Basic Information
| Provider Information | |||||||||
| NPI: | 1861415846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEGE PARK FAMILY CARE CENTER, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMBULATORY SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11725 W 112TH ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134695579 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Practice Location | |||||||||
| Address1: | 11725 W 112TH ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134695579 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 12/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9134690503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | S-046-007 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8500019 | 01 | KS | MEDICARE | OTHER |