Provider Demographics
NPI:1801896915
Name:PROVIDENCE MEDICAL CENTER, INC
Entity type:Organization
Organization Name:PROVIDENCE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-596-4882
Mailing Address - Street 1:8929 PARALLEL PKWY
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66112-1689
Mailing Address - Country:US
Mailing Address - Phone:913-596-4000
Mailing Address - Fax:
Practice Address - Street 1:8929 PARALLEL PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-1689
Practice Address - Country:US
Practice Address - Phone:913-596-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH105003282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS71980OtherAETNA
KS90051016OtherBLUE CROSS OF KANSAS CITY
KS323130OtherFIRST GUARD
KS000729OtherBLUE CROSS OF KANSAS
KS170146Medicare ID - Type UnspecifiedMEDICARE