Provider Demographics
NPI:1871780825
Name:JERAD WIDMAN
Entity type:Organization
Organization Name:JERAD WIDMAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:SEELING
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:913-592-2720
Mailing Address - Street 1:22450 S HARRISON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRING HILL
Mailing Address - State:KS
Mailing Address - Zip Code:66083-8882
Mailing Address - Country:US
Mailing Address - Phone:913-592-2720
Mailing Address - Fax:913-592-2725
Practice Address - Street 1:22450 S HARRISON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRING HILL
Practice Address - State:KS
Practice Address - Zip Code:66083-8882
Practice Address - Country:US
Practice Address - Phone:913-592-2720
Practice Address - Fax:913-592-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS0430763207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
35084012OtherBLUE CROSS BLUE SHIELD KC
KS200300220DMedicaid
KS111144Medicare PIN