Provider Demographics
NPI:1548325772
Name:NORTHWEST MISSOURI PHYSICAL MEDICINE AND REHABILITATION, LLC
Entity type:Organization
Organization Name:NORTHWEST MISSOURI PHYSICAL MEDICINE AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-617-2652
Mailing Address - Street 1:105 FAR WEST DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3500
Mailing Address - Country:US
Mailing Address - Phone:816-271-8182
Mailing Address - Fax:816-271-8183
Practice Address - Street 1:105 FAR WEST DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3500
Practice Address - Country:US
Practice Address - Phone:816-271-8182
Practice Address - Fax:816-271-8183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI340000Medicare ID - Type Unspecified