Healthcare Provider Details

I. General information

NPI: 1023697406
Provider Name (Legal Business Name): IMPACT ORTHOPEDICS & SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 12/24/2021
Certification Date: 12/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 W 94TH TER STE 113
PRAIRIE VILLAGE KS
66207-2522
US

IV. Provider business mailing address

5200 W 94TH TER STE 113
PRAIRIE VILLAGE KS
66207-2522
US

V. Phone/Fax

Practice location:
  • Phone: 913-906-8640
  • Fax: 913-906-8682
Mailing address:
  • Phone: 913-906-8640
  • Fax: 913-906-8682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL GABRIEL AZZAM
Title or Position: OWNER
Credential: MD
Phone: 913-906-8640