Basic Information
| Provider Information | |||||||||
| NPI: | 1740775212 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOCIAL WELFARE BOARD OF THE COUNTY OF BUCHANAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WESTSIDE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 904 S 10TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645032400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162335188 | ||||||||
| FaxNumber: | 8163445247 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 S 10TH ST STE A | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645032400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163445201 | ||||||||
| FaxNumber: | 8163555247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2018 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JUDAH | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | CARMEL | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8163445201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOCIAL WELFARE BOARD OF THE COUNTY OF BUCHANAN | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSN RN | ||||||||
| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0050X | Y | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1497024145 | 05 | MO | MEDICAID |