Provider Demographics
NPI:1710300298
Name:EXCELSIOR SPRINGS PHYSICIANS CLINICS LLC
Entity Type:Organization
Organization Name:EXCELSIOR SPRINGS PHYSICIANS CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIANS PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOOMGARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRMA, BSHSA, EMBA
Authorized Official - Phone:816-629-2623
Mailing Address - Street 1:613 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWSON
Mailing Address - State:MO
Mailing Address - Zip Code:64062-8973
Mailing Address - Country:US
Mailing Address - Phone:816-580-0055
Mailing Address - Fax:816-580-0064
Practice Address - Street 1:1700 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1182
Practice Address - Country:US
Practice Address - Phone:816-629-2623
Practice Address - Fax:816-629-2722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOD0113134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4388OtherMEDICARE ID