Basic Information
| Provider Information | |||||||||
| NPI: | 1013462662 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEARTLAND MEDICAL CLINIC, INC. | ||||||||
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| OtherOrganizationName: | HEARTLAND COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 MAINE ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858417297 | ||||||||
| FaxNumber: | 7858560375 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | OSKALOOSA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660664168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858417297 | ||||||||
| FaxNumber: | 7858560375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2016 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | COVENTON | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7858417297 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEARTLAND MEDICAL CLINIC, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 04-33272 | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | 0528427 | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 200688980A | 05 | KS | MEDICAID |