Provider Demographics
NPI:1629002753
Name:JACKSON COUNTY PULMONARY PC
Entity Type:Organization
Organization Name:JACKSON COUNTY PULMONARY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-478-8113
Mailing Address - Street 1:4911 S ARROWHEAD DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055
Mailing Address - Country:US
Mailing Address - Phone:816-478-8113
Mailing Address - Fax:816-478-8108
Practice Address - Street 1:4911 S ARROWHEAD DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055
Practice Address - Country:US
Practice Address - Phone:816-478-8113
Practice Address - Fax:816-478-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
17529013OtherBCBS
MO503414609Medicaid
MO503414609Medicaid