Provider Demographics
NPI:1073767521
Name:OCCUPATIONAL MEDICINE OF NORTHWEST MISSOURI, LLC
Entity Type:Organization
Organization Name:OCCUPATIONAL MEDICINE OF NORTHWEST MISSOURI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-559-6301
Mailing Address - Street 1:PO BOX 877674
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64187-7674
Mailing Address - Country:US
Mailing Address - Phone:816-561-2105
Mailing Address - Fax:816-559-6383
Practice Address - Street 1:904 EDMOND ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64501-2702
Practice Address - Country:US
Practice Address - Phone:816-233-7702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC0928916261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine