Healthcare Provider Details

I. General information

NPI: 1740248772
Provider Name (Legal Business Name): COLLEGE PARK FAMILY CARE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 03/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11755 W 112TH ST SUITE 101
OVERLAND PARK KS
66210-2761
US

IV. Provider business mailing address

11755 W 112TH ST SUITE 101
OVERLAND PARK KS
66210-2761
US

V. Phone/Fax

Practice location:
  • Phone: 913-469-0503
  • Fax: 913-338-1311
Mailing address:
  • Phone: 913-469-0503
  • Fax: 913-338-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHUCK O. CHAMBERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 913-469-0503