MEDICARE: EXCELSIOR SPRINGS PHYSICIAN CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1851860498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELSIOR SPRINGS PHYSICIAN CLINIC LLC

Provider Business Mailing Address
First Line	:	1700 RAINBOW BLVD
Second Line	:
City	:	EXCELSIOR SPRINGS
State	:	MO
Zip	:	64024-1182
Country	:	US
Telephone Number	:	816-630-6081
Fax Number	:

Provider Business Practice Location Address
First Line	:	25610 PARK RD N
Second Line	:
City	:	LAWSON
State	:	MO
Zip	:	64062-8938
Country	:	US
Telephone Number	:	816-630-6722
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CAMERON MEYER
Credential	:
Telephone Number	:	816-629-2763

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	11/13/2018

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