1568750420 NPI number — EXCELSIOR SPRINGS PEDIATRIC CLINIC

Table of content: (NPI 1568750420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568750420 NPI number — EXCELSIOR SPRINGS PEDIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCELSIOR SPRINGS PEDIATRIC CLINIC
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:
Provider Other Organization Name Type Code:
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:
1568750420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1006 N JESSE JAMES RD
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
EXCELSIOR SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64024-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-637-0117
Provider Business Mailing Address Fax Number:
816-637-0814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 N JESSE JAMES RD
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
EXCELSIOR SPRINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64024-1202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-637-0117
Provider Business Practice Location Address Fax Number:
816-637-0814
Provider Enumeration Date:
07/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
816-637-0117

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  R6H00 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 2011006205 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 202518809 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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