Provider Demographics
NPI:1770649022
Name:BLUE RIVER MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:BLUE RIVER MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDHENKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-373-3006
Mailing Address - Street 1:4911 S ARROWHEAD DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-7005
Mailing Address - Country:US
Mailing Address - Phone:816-373-3006
Mailing Address - Fax:816-373-3087
Practice Address - Street 1:4911 S ARROWHEAD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-7005
Practice Address - Country:US
Practice Address - Phone:816-373-3006
Practice Address - Fax:816-373-3087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151111OtherAETNA
MO32939018OtherBLUE CROSS BLUE SHIELD
MO168067OtherCOVENTRY
MO151111OtherAETNA