Provider Demographics
NPI:1699040006
Name:CARONDELET PHYSICIAN SERVICES, INC.
Entity Type:Organization
Organization Name:CARONDELET PHYSICIAN SERVICES, INC.
Other - Org Name:GRAIN VALLEY FAMILY PHYSICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:VP AND 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 1:1454 SW EAGLES PKWY
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-8508
Practice Address - Country:US
Practice Address - Phone:816-847-2390
Practice Address - Fax:816-847-2392
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARONDELET HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
39532013OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
MO501269500Medicaid
MOY360000Medicare PIN