Provider Demographics
NPI:1356364756
Name:WARRENSBURG MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:WARRENSBURG MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAHAVIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRIDHARANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-429-2128
Mailing Address - Street 1:514 BURKARTH RD
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-3104
Mailing Address - Country:US
Mailing Address - Phone:913-248-9693
Mailing Address - Fax:913-248-9383
Practice Address - Street 1:514 BURKARTH RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-3104
Practice Address - Country:US
Practice Address - Phone:913-248-9693
Practice Address - Fax:913-248-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1A87207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO29181021OtherBLUE SHIELD KANSAS CITY
MOK720000Medicare PIN
MOT990000Medicare ID - Type Unspecified