Healthcare Provider Details

I. General information

NPI: 1609946383
Provider Name (Legal Business Name): PEDIATRIC PARTNERS,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 W 133RD ST SUITE 102
OVERLAND PARK KS
66213-4750
US

IV. Provider business mailing address

7301 W 133RD ST SUITE 102
OVERLAND PARK KS
66213-4750
US

V. Phone/Fax

Practice location:
  • Phone: 913-888-4567
  • Fax: 913-888-1277
Mailing address:
  • Phone: 913-888-4567
  • Fax: 913-888-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0517101
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JENNIFER R MELLICK
Title or Position: CEO
Credential: M.D.
Phone: 913-888-4567