Healthcare Provider Details

I. General information

NPI: 1104691450
Provider Name (Legal Business Name): KSMO ORTHOPEDICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 W 137TH ST
OVERLAND PARK KS
66224-5940
US

IV. Provider business mailing address

710 N DEARBORN ST
CHICAGO IL
60654-5900
US

V. Phone/Fax

Practice location:
  • Phone: 913-427-0060
  • Fax: 913-372-5792
Mailing address:
  • Phone: 312-819-2849
  • Fax: 312-981-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROSEMARIE ISAILY
Title or Position: SR VP OF OPERATIONS
Credential:
Phone: 312-819-2849