NPIMap

Organization Active NPI

Blue Valley Dermatology LLC

  • Dermatology Physician
  • Overland Park, KS
National Provider Identifier
1104354794
Registry record updated Oct 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
04-36968 Issued in KS
Legal business name
BLUE VALLEY DERMATOLOGY LLC
Practice address
7840 W 165TH Street
Suite 260
Overland Park, KS 66223
Phone
(415) 802-1310
NPI assigned
May 26, 2017
Last updated
Oct 25, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 25, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tom Tkachuk
Title
Manager
Phone
(415) 802-1310

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X 04-36968 KS Primary

Addresses

Primary practice location

7840 W 165TH Street
Suite 260
Overland Park, KS 66223

Mailing address

7840 W 165TH Street
Suite 260
Overland Park, KS 66223
Phone (415) 802-1310

Other practice location 1

7520 W 160th St Ste 100
Overland Park, KS 66085-8137
Phone (913) 871-8221

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in KS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170726003732 KS Part B Supplier - Clinic/Group Practice 9133499973 Receives reassigned benefits from 12 practitioners
Practice locations: Overland Park, KS

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
17D1105979Blue Valley Dermatology7520 West 160TH Street, Overland Park, KS 66085ComplianceDec 27, 2027

National Provider Directory

National Provider Directory

Locations

7520 W 160th St
Stilwell, KS 66085
Phone (913) 871-8221

7520 W 160th St
Ste 100
Stilwell, KS 66085
Phone (913) 871-8221

7520 W 160th St
Ste 200
Stilwell, KS 66085

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1495756800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635120000000",
    "number": "1104354794",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7840 W 165TH STREET",
            "address_2": "SUITE 260",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "66223",
            "telephone_number": "415-802-1310"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7840 W 165TH STREET",
            "address_2": "SUITE 260",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "66223",
            "telephone_number": "415-802-1310"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7520 W 160th St Ste 100",
            "address_purpose": "LOCATION",
            "city": "Overland Park",
            "state": "KS",
            "postal_code": "660858137",
            "country_code": "US",
            "telephone_number": "913-871-8221",
            "fax_number": "913-495-5456",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BLUE VALLEY DERMATOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-26",
        "last_updated": "2021-10-25",
        "certification_date": "2021-10-25",
        "status": "A",
        "authorized_official_last_name": "TKACHUK",
        "authorized_official_first_name": "TOM",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "415-802-1310"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "KS",
            "license": "04-36968",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Overland Park, KS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.