Basic Information
| Provider Information | |||||||||
| NPI: | 1982018719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARONDELET PHYSICIAN SERVICES, INC | ||||||||
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| OtherOrganizationName: | CARONDELET FAMILY MEDICAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 NW SAINT MARY DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166555791 | ||||||||
| FaxNumber: | 8166555457 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 CARONDELET DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641144855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169437777 | ||||||||
| FaxNumber: | 8169437778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLEARY | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8169432819 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARONDELET HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 39532013 | 01 | BCBS OF KANSAS CITY | OTHER | 501269500 | 05 | MO | MEDICAID |