Basic Information
| Provider Information | |||||||||
| NPI: | 1043556400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KANSAS MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ST ROSE FAMILY MEDICINE & URGENT CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960462 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3515 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202722514 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHAN | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6202722561 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.