Provider Demographics
NPI:1811232796
Name:EXCELSIOR SPRINGS PHYSICIAN CLINIC LLC
Entity Type:Organization
Organization Name:EXCELSIOR SPRINGS PHYSICIAN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT FINANCIAL SERVICES DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-629-2790
Mailing Address - Street 1:1700 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-1182
Mailing Address - Country:US
Mailing Address - Phone:816-630-6081
Mailing Address - Fax:816-629-3661
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:816-630-6081
Practice Address - Fax:816-629-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4388Medicare Oscar/Certification