Provider Demographics
NPI:1609084540
Name:DICKSON DIVELEY MIDWEST ORTHOPAEDIC CLINIC LLC
Entity type:Organization
Organization Name:DICKSON DIVELEY MIDWEST ORTHOPAEDIC CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:S
Authorized Official - Last Name:STUEVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-851-7780
Mailing Address - Street 1:3651 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1910
Mailing Address - Country:US
Mailing Address - Phone:913-319-7600
Mailing Address - Fax:913-253-1703
Practice Address - Street 1:3651 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1910
Practice Address - Country:US
Practice Address - Phone:913-319-7600
Practice Address - Fax:913-253-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0884840002Medicare NSC
MO0884840001Medicare NSC