Provider Demographics
NPI:1952393977
Name:THE LIBERTY CLINIC, INC.
Entity Type:Organization
Organization Name:THE LIBERTY CLINIC, INC.
Other - Org Name:THE LIBERTY CLINIC, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:CROSSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-781-7200
Mailing Address - Street 1:2525 GLENN HENDREN DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9625
Mailing Address - Country:US
Mailing Address - Phone:816-781-7200
Mailing Address - Fax:816-792-7117
Practice Address - Street 1:122 S STEWART RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-4205
Practice Address - Country:US
Practice Address - Phone:816-781-7730
Practice Address - Fax:816-415-1886
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW LIBERTY HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X, 207R00000X, 207V00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208107406Medicaid
MO208107406Medicaid