Provider Demographics
NPI:1548462799
Name:BOULWARE MEDICAL CLINIC L.L.C.
Entity type:Organization
Organization Name:BOULWARE MEDICAL CLINIC L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOULWARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-792-5577
Mailing Address - Street 1:1131 W KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2281
Mailing Address - Country:US
Mailing Address - Phone:816-792-5577
Mailing Address - Fax:816-792-5141
Practice Address - Street 1:1131 W KANSAS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2281
Practice Address - Country:US
Practice Address - Phone:816-792-5577
Practice Address - Fax:816-792-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19532014OtherBLUE CROSS GROUP
MOD700000AMedicare ID - Type Unspecified