Healthcare Provider Details

I. General information

NPI: 1124609425
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 N LUCERNE AVE
KANSAS CITY MO
64151-3105
US

IV. Provider business mailing address

3107 FREDERICK AVE STE B
SAINT JOSEPH MO
64506-3082
US

V. Phone/Fax

Practice location:
  • Phone: 816-569-1802
  • Fax: 816-569-1882
Mailing address:
  • Phone: 816-233-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL ANN KIDWELL
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 816-233-9888