Provider Demographics
NPI:1144348012
Name:INDEPENDENCE SURGICAL CLINIC, INC.
Entity type:Organization
Organization Name:INDEPENDENCE SURGICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MINDI
Authorized Official - Middle Name:SUZANNE THOMPSON
Authorized Official - Last Name:BEAHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-373-4646
Mailing Address - Street 1:19550 EAST 39TH STREET S
Mailing Address - Street 2:SUITE 325
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2310
Mailing Address - Country:US
Mailing Address - Phone:816-373-4646
Mailing Address - Fax:816-373-7831
Practice Address - Street 1:19550 EAST 39TH STREET S
Practice Address - Street 2:SUITE 325
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2310
Practice Address - Country:US
Practice Address - Phone:816-373-4646
Practice Address - Fax:816-373-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105155208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00486013OtherBCBS
MO200395002Medicaid