1699040006 NPI number — CARONDELET PHYSICIAN SERVICES, INC.

Table of content: (NPI 1699040006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699040006 NPI number — CARONDELET PHYSICIAN SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARONDELET PHYSICIAN SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRAIN VALLEY FAMILY PHYSICIANS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699040006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 NW SAINT MARY DR
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
BLUE SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64014-2524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-655-5792
Provider Business Mailing Address Fax Number:
816-655-5787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1454 SW EAGLES PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAIN VALLEY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64029-8508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-847-2390
Provider Business Practice Location Address Fax Number:
816-847-2392
Provider Enumeration Date:
03/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CLEARY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
VP AND CFO
Authorized Official Telephone Number:
816-943-2819

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  106682 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39532013 . This is a "BLUE CROSS BLUE SHIELD OF KANSAS CITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 501269500 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com