Basic Information
| Provider Information | |||||||||
| NPI: | 1386699718 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON COUNTY GASTROENTEROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 412622 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641412622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162291191 | ||||||||
| FaxNumber: | 8162291198 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 NW MOCK AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162291191 | ||||||||
| FaxNumber: | 8162291198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 12/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | VARDAKIS | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8162291191 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.