Provider Demographics
NPI:1962424895
Name:ST JOSEPH SPECIALTY CLINIC PC
Entity type:Organization
Organization Name:ST JOSEPH SPECIALTY CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-866-5105
Mailing Address - Street 1:PO BOX 8657
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64508-8657
Mailing Address - Country:US
Mailing Address - Phone:816-866-5105
Mailing Address - Fax:816-207-0454
Practice Address - Street 1:2600 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2701
Practice Address - Country:US
Practice Address - Phone:660-425-0253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112862208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208865105Medicaid
MO16551737OtherMO TAX ID NUMBER