Basic Information
| Provider Information | |||||||||
| NPI: | 1477044840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LIBERTY HOSPITAL COPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE PULMONARY & SLEEP CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2609 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164074555 | ||||||||
| FaxNumber: | 8164072362 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR STE 402 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167818445 | ||||||||
| FaxNumber: | 8167818413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2018 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | FEESS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8167817200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 58197016 | 01 | MO | BLUE KC | OTHER |