Basic Information
| Provider Information | |||||||||
| NPI: | 1881803229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEGE PARK FAMILY CARE CENTER, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLLEGE PARK RADIOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11755 W 112TH ST | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134690503 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Practice Location | |||||||||
| Address1: | 11755 W 112TH ST | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134690503 | ||||||||
| FaxNumber: | 9133381311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/10/2007 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERS | ||||||||
| AuthorizedOfficialFirstName: | CHUCK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9134690503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0484665 | 01 | KS | AETNA | OTHER | 5696741 | 01 | KS | AETNA | OTHER |