Healthcare Provider Details

I. General information

NPI: 1578564480
Provider Name (Legal Business Name): UROGYNECOLOGY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 W 106TH STREET SUITE 130
OVERLAND PARK KS
66215-2300
US

IV. Provider business mailing address

6730 W 121ST ST
OVERLAND PARK KS
66209-2002
US

V. Phone/Fax

Practice location:
  • Phone: 913-307-0044
  • Fax: 913-227-0094
Mailing address:
  • Phone: 913-307-0044
  • Fax: 913-227-0094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number22411
License Number StateKS

VIII. Authorized Official

Name: MR. CHARLES W BUTRICK
Title or Position: DIRECTOR
Credential: MD
Phone: 913-307-0044