Healthcare Provider Details

I. General information

NPI: 1144277880
Provider Name (Legal Business Name): JACKSON COUNTY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17221 E 23RD ST S SUITE 100
INDEPENDENCE MO
64057-1803
US

IV. Provider business mailing address

17221 E 23RD ST S SUITE 100
INDEPENDENCE MO
64057-1803
US

V. Phone/Fax

Practice location:
  • Phone: 816-350-0005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK J KUENY
Title or Position: VP
Credential:
Phone: 816-350-0005