Provider Demographics
NPI:1982018719
Name:CARONDELET PHYSICIAN SERVICES, INC
Entity Type:Organization
Organization Name:CARONDELET PHYSICIAN SERVICES, INC
Other - Org Name:CARONDELET FAMILY MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/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:816-655-5791
Mailing Address - Fax:816-655-5457
Practice Address - Street 1:930 CARONDELET DR
Practice Address - Street 2:SUITE 304
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4855
Practice Address - Country:US
Practice Address - Phone:816-943-7777
Practice Address - Fax:816-943-7778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARONDELET HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
39532013OtherBCBS OF KANSAS CITY
MO501269500Medicaid
MOY360000Medicare PIN