Basic Information
| Provider Information | |||||||||
| NPI: | 1922322676 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDAMERICARE LIMITED LIABILITY COMPANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SW 13TH ST | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640813800 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6301 E 125TH ST | ||||||||
| Address2: | |||||||||
| City: | GRANDVIEW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640301884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165167114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | ERISMAN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8165167114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2007006349 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.