=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548462799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOULWARE MEDICAL CLINIC L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 07/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1131 W KANSAS ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-792-5577
-----------------------------------------------------
Fax | 816-792-5141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1131 W KANSAS ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-792-5577
-----------------------------------------------------
Fax | 816-792-5141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR.
-----------------------------------------------------
Name | DR. ROBERT J BOULWARE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 816-792-5577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------