Provider Demographics
NPI:1467758144
Name:CARONDELET PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:CARONDELET PHYSICIAN SERVICES INC
Other - Org Name:FAMILY MEDICAL CARE ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-943-2819
Mailing Address - Street 1:801 NW SAINT MARY DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2524
Mailing Address - Country:US
Mailing Address - Phone:816-655-5792
Mailing Address - Fax:816-655-5787
Practice Address - Street 1:100 NW MOCK AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2501
Practice Address - Country:US
Practice Address - Phone:816-228-1000
Practice Address - Fax:816-463-6035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARONDELET HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-28
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3D26207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501269500Medicaid
39532013OtherBCBS OF KANSAS CITY
39532013OtherBCBS OF KANSAS CITY