Healthcare Provider Details

I. General information

NPI: 1992964845
Provider Name (Legal Business Name): INDEPENDENCE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17500 MEDICAL CENTER PKWY SUITE 5
INDEPENDENCE MO
64057
US

IV. Provider business mailing address

17500 MEDICAL CENTER PKWY SUITE 5
INDEPENDENCE MO
64057
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-1111
  • Fax: 816-378-9222
Mailing address:
  • Phone: 816-373-1111
  • Fax: 816-378-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRACEY FARIBORZ
Title or Position: OFFICE MANAGER
Credential: LPN
Phone: 816-373-1142