Provider Demographics
NPI:1376784835
Name:MIDTOWN FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:MIDTOWN FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-756-5839
Mailing Address - Street 1:3406 BROADWAY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2767
Mailing Address - Country:US
Mailing Address - Phone:816-756-5839
Mailing Address - Fax:816-756-5874
Practice Address - Street 1:3406 BROADWAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2767
Practice Address - Country:US
Practice Address - Phone:816-756-5839
Practice Address - Fax:816-756-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36683207Q00000X, 261QP2300X
MO2008013774261QP2300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208229112Medicaid
MO1770779530Medicaid
MOB23391Medicare UPIN