=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174156343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE'S SUMMIT PHYSICIANS GROUP - INTERNAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2020
-----------------------------------------------------
Last Update Date | 02/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 NW BLUE PKWY
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64086-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-524-3223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 NW BLUE PKWY
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64086-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | CHAD FLETCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-524-3223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------