Provider Demographics
NPI:1922054295
Name:INDEPENDENCE REGIONAL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:INDEPENDENCE REGIONAL MEDICAL GROUP LLC
Other - Org Name:HERITAGE PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7600
Mailing Address - Street 1:17421 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1805
Mailing Address - Country:US
Mailing Address - Phone:816-356-2000
Mailing Address - Fax:816-737-1796
Practice Address - Street 1:17421 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1805
Practice Address - Country:US
Practice Address - Phone:816-356-2000
Practice Address - Fax:816-737-1796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506088202Medicaid
KS100452440AMedicaid
KS100452440BMedicaid
KS100452440AMedicaid
KS100452440BMedicaid