Basic Information
| Provider Information | |||||||||
| NPI: | 1013067768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLOUTH MEDICAL CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | JEFFERSON COUNTY HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | 313 S. UNION STREET | ||||||||
| City: | MC LOUTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660540160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137966116 | ||||||||
| FaxNumber: | 9137962222 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 SOUTH UNION STREET | ||||||||
| Address2: | |||||||||
| City: | MC LOUTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660540160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137966116 | ||||||||
| FaxNumber: | 9137962222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEPHAN | ||||||||
| AuthorizedOfficialFirstName: | LORENE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9137966116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ARNP-C | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.