Healthcare Provider Details

I. General information

NPI: 1568750420
Provider Name (Legal Business Name): EXCELSIOR SPRINGS PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 N JESSE JAMES RD STE 2
EXCELSIOR SPRINGS MO
64024-1202
US

IV. Provider business mailing address

1006 N JESSE JAMES RD STE 2
EXCELSIOR SPRINGS MO
64024-1202
US

V. Phone/Fax

Practice location:
  • Phone: 816-637-0117
  • Fax: 816-637-0814
Mailing address:
  • Phone: 816-637-0117
  • Fax: 816-637-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR6H00
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011006205
License Number StateMO

VIII. Authorized Official

Name: KELLI L BOWMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 816-637-0117