Provider Demographics
NPI:1194762930
Name:LIBERTY MEDICINE SPECIALISTS, INC.
Entity type:Organization
Organization Name:LIBERTY MEDICINE SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:G
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-781-8100
Mailing Address - Street 1:550 RUSH CREEK PKWY
Mailing Address - Street 2:STE B
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9604
Mailing Address - Country:US
Mailing Address - Phone:816-781-8100
Mailing Address - Fax:816-781-3374
Practice Address - Street 1:550 RUSH CREEK PKWY
Practice Address - Street 2:STE B
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9604
Practice Address - Country:US
Practice Address - Phone:816-781-8100
Practice Address - Fax:816-781-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6J63207R00000X
MO110760207R00000X
MOR8A47207R00000X
MOR4935207RE0101X
MO109247207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502511207Medicaid
MO06797011OtherBCBS GROUP NUMBER
MO502511207Medicaid