MEDICARE: STATE LINE MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29398029	OTHER	MO	BCBS OF KC

General Provider Information

NPI Number	:	1679529853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE LINE MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	7611 STATE LINE RD
Second Line	:	SUITE 103
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-6801
Country	:	US
Telephone Number	:	816-333-9886
Fax Number	:

Provider Business Practice Location Address
First Line	:	7611 STATE LINE RD
Second Line	:	SUITE 103
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-6801
Country	:	US
Telephone Number	:	816-333-9886
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	KEN WASHINGTON
Credential	:
Telephone Number	:	816-333-9886

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	08/22/2020

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Directions to “STATE LINE MEDICAL GROUP LLC ” Practice Location

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