Provider Demographics
NPI:1407803273
Name:MEDICAL GROUP OF KANSAS CITY, LLC
Entity Type:Organization
Organization Name:MEDICAL GROUP OF KANSAS CITY, LLC
Other - Org Name:THE MEDICAL GROUP OF KANSAS CITY, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-508-4090
Mailing Address - Street 1:PO BOX 403453
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3453
Mailing Address - Country:US
Mailing Address - Phone:816-363-7710
Mailing Address - Fax:816-363-8414
Practice Address - Street 1:6675 HOLMES RD
Practice Address - Street 2:SUITE 550
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1167
Practice Address - Country:US
Practice Address - Phone:816-363-7710
Practice Address - Fax:816-363-8414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO24143031OtherBCBS OF KANSAS
KS100452640BMedicaid
MO501165203Medicaid
KS100452640AMedicaid
KS100452640AMedicaid
MO501165203Medicaid
KSP010000AMedicare PIN
P010000AMedicare PIN