Healthcare Provider Details

I. General information

NPI: 1427526458
Provider Name (Legal Business Name): PHYSICIANS WELLNESS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19045 E VALLEY VIEW PARKWAY, SUITE G
INDEPENDENCE MO
64055
US

IV. Provider business mailing address

1920 EAST STATE HIGHWAY 114
SOUTHLAKE TX
76092
US

V. Phone/Fax

Practice location:
  • Phone: 816-398-7171
  • Fax: 816-398-7222
Mailing address:
  • Phone: 817-410-3800
  • Fax: 817-410-6466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM G REILLY
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 817-410-3800