Basic Information
| Provider Information | |||||||||
| NPI: | 1851336564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHLAND CHEST CONSULTANTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2521 GLENN HENDREN DR | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167818445 | ||||||||
| FaxNumber: | 8167818413 | ||||||||
| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167818445 | ||||||||
| FaxNumber: | 8167818413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | LOGGAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8167818445 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MDR7E84 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 11804014 | 01 | MO | BCBS | OTHER | 50328103 | 05 | MO | MEDICAID |