Healthcare Provider Details

I. General information

NPI: 1255545737
Provider Name (Legal Business Name): INDEPENDENCE MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17601 E US HIGHWAY 40 SUITE S
INDEPENDENCE MO
64055-5434
US

IV. Provider business mailing address

17601 E US HIGHWAY 40 SUITE S
INDEPENDENCE MO
64055-5434
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-0655
  • Fax: 816-478-6374
Mailing address:
  • Phone: 816-373-0655
  • Fax: 816-478-6374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number103646
License Number StateMO

VIII. Authorized Official

Name: DR. WILLIAM V ANDREWS
Title or Position: PHYSICIAN PRESIDENT
Credential: M.D.
Phone: 816-373-0655