=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366441966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSOCIATED PLASTIC SURGEONS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2005
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11501 GRANADA ST
-----------------------------------------------------
City | LEAWOOD
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66211-1454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-451-3722
-----------------------------------------------------
Fax | 913-451-5000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11501 GRANADA ST
-----------------------------------------------------
City | LEAWOOD
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66211-1454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-451-3722
-----------------------------------------------------
Fax | 913-451-5000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | ELIZABETH LISA G JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-451-3722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------