Basic Information
| Provider Information | |||||||||
| NPI: | 1609268994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDAMERICARE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165167114 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165167114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2015 | ||||||||
| LastUpdateDate: | 02/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | ERISMAN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8165167114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.