Basic Information
| Provider Information | |||||||||
| NPI: | 1053481689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LESTER E COX MEDICAL CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REGIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 802843 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641802843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177306430 | ||||||||
| FaxNumber: | 4172697567 | ||||||||
| Practice Location | |||||||||
| Address1: | 806 SW COLLINS AVENUE | ||||||||
| Address2: | |||||||||
| City: | AVA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176837200 | ||||||||
| FaxNumber: | 4176830165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAMEL | ||||||||
| AuthorizedOfficialFirstName: | BROCK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4172694368 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 505978502 | 05 | MO | MEDICAID |