Healthcare Provider Details

I. General information

NPI: 1952393977
Provider Name (Legal Business Name): THE LIBERTY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S STEWART RD
LIBERTY MO
64068-4205
US

IV. Provider business mailing address

2525 GLENN HENDREN DR
LIBERTY MO
64068-9625
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-7730
  • Fax: 816-415-1886
Mailing address:
  • Phone: 816-781-7200
  • Fax: 816-792-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMO

VIII. Authorized Official

Name: JOSEPH W CROSSETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 816-781-7200