Basic Information
| Provider Information | |||||||||
| NPI: | 1326094632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY CARE OF E. JACKSON COUNTY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153725426 | ||||||||
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| Practice Location | |||||||||
| Address1: | 725 NW STATE ROUTE 7 STE B | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162298187 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | SYKES | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8163637303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100452280A | 05 | KS | MEDICAID | 506899004 | 05 | MO | MEDICAID | 20051024 | 01 | KS | BCBS OF KANSAS | OTHER |