Provider Demographics
NPI:1386699718
Name:JACKSON COUNTY GASTROENTEROLOGY PC
Entity type:Organization
Organization Name:JACKSON COUNTY GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:VARDAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-229-1191
Mailing Address - Street 1:PO BOX 412622
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-2622
Mailing Address - Country:US
Mailing Address - Phone:816-229-1191
Mailing Address - Fax:816-229-1198
Practice Address - Street 1:206 NW MOCK AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2507
Practice Address - Country:US
Practice Address - Phone:816-229-1191
Practice Address - Fax:816-229-1198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR140000Medicare ID - Type Unspecified