Provider Demographics
NPI:1023697406
Name:IMPACT ORTHOPEDICS & SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:IMPACT ORTHOPEDICS & SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:AZZAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-906-8640
Mailing Address - Street 1:5200 W 94TH TER STE 113
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2522
Mailing Address - Country:US
Mailing Address - Phone:913-906-8640
Mailing Address - Fax:913-906-8682
Practice Address - Street 1:5200 W 94TH TER STE 113
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207-2522
Practice Address - Country:US
Practice Address - Phone:913-906-8640
Practice Address - Fax:913-906-8682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-05
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty