Healthcare Provider Details

I. General information

NPI: 1922358902
Provider Name (Legal Business Name): MENORAH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W 119TH ST SUITE 308
OVERLAND PARK KS
66209-3721
US

IV. Provider business mailing address

PO BOX 741205
ATLANTA GA
30374-1205
US

V. Phone/Fax

Practice location:
  • Phone: 913-491-3724
  • Fax: 913-491-1281
Mailing address:
  • Phone: 913-491-3724
  • Fax: 913-491-1281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: CINDY BERGMEIER
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 913-491-3724