Provider Demographics
NPI:1861701575
Name:MIDWEST MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:MIDWEST MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:SABET
Authorized Official - Last Name:EDALATI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:913-406-1292
Mailing Address - Street 1:15418 IRON HORSE CIR
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-3852
Mailing Address - Country:US
Mailing Address - Phone:913-406-1292
Mailing Address - Fax:
Practice Address - Street 1:11227 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-1399
Practice Address - Country:US
Practice Address - Phone:913-730-1100
Practice Address - Fax:913-730-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA1865Medicare PIN