Provider Demographics
NPI:1568750420
Name:EXCELSIOR SPRINGS PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:EXCELSIOR SPRINGS PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-637-0117
Mailing Address - Street 1:1006 N JESSE JAMES RD
Mailing Address - Street 2:STE 2
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-1202
Mailing Address - Country:US
Mailing Address - Phone:816-637-0117
Mailing Address - Fax:816-637-0814
Practice Address - Street 1:1006 N JESSE JAMES RD
Practice Address - Street 2:STE 2
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1202
Practice Address - Country:US
Practice Address - Phone:816-637-0117
Practice Address - Fax:816-637-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6H00208000000X
MO2011006205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202518809Medicaid