Provider Demographics
NPI:1396753422
Name:RANDY S. BUCKLES, DO, FAMILY HEALTH CARE, LLC
Entity type:Organization
Organization Name:RANDY S. BUCKLES, DO, FAMILY HEALTH CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BUCKLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-676-1300
Mailing Address - Street 1:220 SOUTH WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506
Mailing Address - Country:US
Mailing Address - Phone:816-676-1300
Mailing Address - Fax:816-676-1400
Practice Address - Street 1:220 SOUTH WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506
Practice Address - Country:US
Practice Address - Phone:816-676-1300
Practice Address - Fax:816-676-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO458858OtherFREEDOM/HEALTHLINK ID
MO10001359400OtherCHP ID
MO27020012OtherBCKC GRP ID
MO458828OtherHEALTHLINK GRP ID
MOCH5327OtherRAILROAD RETIREMENT BOARD
MO10001359400OtherCOMMUNITY HEALTH PLAN
MO2326850OtherAETNA PROV ID
MO499640064OtherWPS/WEST REG. CLAIMS ID
MO505804906Medicaid
MO=========OtherWPS TRICARE FOR LIFE ID
MO458858OtherFREEDOM/HEALTHLINK ID
MO499640064OtherWPS/WEST REG. CLAIMS ID
MO4761830001Medicare NSC