Basic Information
| Provider Information | |||||||||
| NPI: | 1922054295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDEPENDENCE REGIONAL MEDICAL GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HERITAGE PHYSICIANS GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17421 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640571805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163562000 | ||||||||
| FaxNumber: | 8167371796 | ||||||||
| Practice Location | |||||||||
| Address1: | 17421 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640571805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163562000 | ||||||||
| FaxNumber: | 8167371796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 04/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | JOSEPH | ||||||||
| AuthorizedOfficialFirstName: | LOUIS | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6153737600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 506088202 | 05 | MO | MEDICAID | 100452440A | 05 | KS | MEDICAID | 100452440B | 05 | KS | MEDICAID |