Healthcare Provider Details

I. General information

NPI: 1811293582
Provider Name (Legal Business Name): CARONDELET PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 S BROADWAY
OAK GROVE MO
64075-9020
US

IV. Provider business mailing address

801 NW SAINT MARY DR SUITE 230
BLUE SPRINGS MO
64014-2524
US

V. Phone/Fax

Practice location:
  • Phone: 816-690-6566
  • Fax: 816-625-8276
Mailing address:
  • Phone: 816-655-5792
  • Fax: 816-655-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34421
License Number StateMO

VIII. Authorized Official

Name: MR. STEVEN R CLEARY
Title or Position: VP/CFO
Credential:
Phone: 816-943-2819