Provider Demographics
NPI:1093884504
Name:NORTHLAND GASTROENTEROLOGY
Entity Type:Organization
Organization Name:NORTHLAND GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:E
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-554-3838
Mailing Address - Street 1:1345 N JESSE JAMES RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-1183
Mailing Address - Country:US
Mailing Address - Phone:816-630-0900
Mailing Address - Fax:816-637-3250
Practice Address - Street 1:1345 N JESSE JAMES RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1183
Practice Address - Country:US
Practice Address - Phone:816-630-0900
Practice Address - Fax:816-637-3250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9779207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09040299OtherBCBS
MO09040299OtherBCBS