Basic Information
| Provider Information | |||||||||
| NPI: | 1013146448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY CARDIOVASCULAR SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2521 GLENN HENDREN DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164075430 | ||||||||
| FaxNumber: | 8164075435 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164075430 | ||||||||
| FaxNumber: | 8164075435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | CROSSETT | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8167817200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEW LIBERTY HOSPITAL DISTRICT OF CLAY COUNTY MISSOURI | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.