Provider Demographics
NPI:1063693232
Name:CARONDELET PHYSICIAN SERVICES INC.
Entity type:Organization
Organization Name:CARONDELET PHYSICIAN SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-943-2819
Mailing Address - Street 1:801 NW SAINT MARY DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2524
Mailing Address - Country:US
Mailing Address - Phone:816-655-5792
Mailing Address - Fax:816-655-5787
Practice Address - Street 1:220 NW RD MIZE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2527
Practice Address - Country:US
Practice Address - Phone:816-228-9841
Practice Address - Fax:816-228-1514
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARONDELET HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-16
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0431315207Q00000X
MO2006003132207RE0101X
MOR8H50207RP1001X
MO2004006974207V00000X
MO100628207X00000X
MO20100081192084N0400X
MOR4B19208600000X
MO35929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200640420AMedicaid
39532013OtherBLUE CROSS BLUE SHIELD
MO501269500Medicaid
KS200640420AMedicaid
MOY360000Medicare PIN
MO501269500Medicaid
MO6076320003Medicare NSC
MOMA1922Medicare PIN