Basic Information
| Provider Information | |||||||||
| NPI: | 1104827781 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY EMERGENCY PHYSICIANS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 411375 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641411375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167819222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640689625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167927000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROBB | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8163917597 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30768018 | 01 | MO | BLUE CROSS BLUE SHIELD MO | OTHER | 505906701 | 05 | MO | MEDICAID |