=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194762930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY MEDICINE SPECIALISTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 04/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 RUSH CREEK PKWY STE B
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-8100
-----------------------------------------------------
Fax | 816-781-3374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 RUSH CREEK PKWY STE B
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-9604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-781-8100
-----------------------------------------------------
Fax | 816-781-3374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DONNA G WELCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-781-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R6J63
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 110760
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R8A47
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 109247
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | R4935
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------