Provider Demographics
NPI:1962809947
Name:PRIME HEALTHCARE SERVICES BLUE SPRINGS, LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES BLUE SPRINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-235-4400
Mailing Address - Street 1:201 NW R D MIZE RD
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2513
Mailing Address - Country:US
Mailing Address - Phone:816-228-5900
Mailing Address - Fax:
Practice Address - Street 1:201 NW R D MIZE RD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2513
Practice Address - Country:US
Practice Address - Phone:816-228-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME HEALTHCARE SERVICES BLUE SPRINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO403-20273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11444403Medicaid
431284526OtherTRICARE
MO11444403Medicaid