Provider Demographics
NPI:1255545737
Name:INDEPENDENCE MEDICAL GROUP PC
Entity type:Organization
Organization Name:INDEPENDENCE MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:V
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-373-0655
Mailing Address - Street 1:17601 E US HIGHWAY 40
Mailing Address - Street 2:SUITE S
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5434
Mailing Address - Country:US
Mailing Address - Phone:816-373-0655
Mailing Address - Fax:816-478-6374
Practice Address - Street 1:17601 E US HIGHWAY 40
Practice Address - Street 2:SUITE S
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5434
Practice Address - Country:US
Practice Address - Phone:816-373-0655
Practice Address - Fax:816-478-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty