Healthcare Provider Details

I. General information

NPI: 1881765337
Provider Name (Legal Business Name): MIDWEST PLASTIC SURGERY AND LASER CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 S ARROWHEAD DR
INDEPENDENCE MO
64055-6980
US

IV. Provider business mailing address

4820 S ARROWHEAD DR
INDEPENDENCE MO
64055-6980
US

V. Phone/Fax

Practice location:
  • Phone: 816-795-5262
  • Fax: 816-795-8979
Mailing address:
  • Phone: 816-795-5262
  • Fax: 816-795-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number85-9
License Number StateMO

VIII. Authorized Official

Name: DR. JEROME P. LAMB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 816-795-5262