Healthcare Provider Details

I. General information

NPI: 1477914471
Provider Name (Legal Business Name): DR.E.T.'S CONCIERGE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12140 NALL AVE STE 305
LEAWOOD KS
66209-2501
US

IV. Provider business mailing address

12140 NALL AVE STE 305
LEAWOOD KS
66209-2501
US

V. Phone/Fax

Practice location:
  • Phone: 913-735-3873
  • Fax:
Mailing address:
  • Phone: 913-735-3873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number0424799
License Number StateKS

VIII. Authorized Official

Name: DR. SUKUMAR ETHIRAJAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 913-735-3873