Provider Demographics
NPI:1982931655
Name:SAMUEL U. RODGERS HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SAMUEL U. RODGERS HEALTH CENTER, INC.
Other - Org Name:SAMUEL U. RODGERS HEALTH CENTER CLAY COUNTY FAMILY MEDICINE & DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-474-4920
Mailing Address - Street 1:825 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2323
Mailing Address - Country:US
Mailing Address - Phone:816-474-4920
Mailing Address - Fax:816-889-1845
Practice Address - Street 1:800 HAINES DRIVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068
Practice Address - Country:US
Practice Address - Phone:816-792-1575
Practice Address - Fax:816-889-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-17
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QF0400X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504119702Medicaid
MO261043Medicare Oscar/Certification