Healthcare Provider Details

I. General information

NPI: 1275611444
Provider Name (Legal Business Name): VEIN CLINIC OF GREATER KANSAS CITY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 109TH ST STE 150
OVERLAND PARK KS
66211-1319
US

IV. Provider business mailing address

4400 W 109TH ST STE 150
OVERLAND PARK KS
66211-1319
US

V. Phone/Fax

Practice location:
  • Phone: 913-541-3377
  • Fax: 913-541-8082
Mailing address:
  • Phone: 913-541-3377
  • Fax: 913-541-8082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0418701
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0418958
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number72262
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number72262
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DAPHENE R ROORDA
Title or Position: OFFICE MNAGER
Credential:
Phone: 913-541-3377