=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285755330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVAMED EYE SURGERY CENTER OF OVERLAND PARK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 10/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5520 COLLEGE BLVD
-----------------------------------------------------
City | OVERLAND PARK
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66211-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-491-3040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12239 COLLECTIONS CENTER DRIVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60693-0122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-906-6570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER AND AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JENNIFER BOYD BALDOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-234-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------