Provider Demographics
NPI:1699721951
Name:CEDAR CREEK MEDICAL GROUP LLC
Entity type:Organization
Organization Name:CEDAR CREEK MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:KUENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-463-6001
Mailing Address - Street 1:100 NW MOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2500
Mailing Address - Country:US
Mailing Address - Phone:816-463-6001
Mailing Address - Fax:816-463-6004
Practice Address - Street 1:100 NW MOCK AVE
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2501
Practice Address - Country:US
Practice Address - Phone:816-463-6001
Practice Address - Fax:816-463-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200543790 AMedicaid
MO500672704Medicaid
KS200543790 AMedicaid