Provider Demographics
NPI:1992964845
Name:INDEPENDENCE PEDIATRICS PC
Entity type:Organization
Organization Name:INDEPENDENCE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARIBORZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:816-373-1142
Mailing Address - Street 1:17500 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057
Mailing Address - Country:US
Mailing Address - Phone:816-373-1111
Mailing Address - Fax:816-378-9222
Practice Address - Street 1:17500 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 5
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-373-1111
Practice Address - Fax:816-378-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
33997011OtherBCBS