Basic Information
| Provider Information | |||||||||
| NPI: | 1053862805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COFFEYVILLE REGIONAL MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202511200 | ||||||||
| FaxNumber: | 6202521562 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 W 4TH ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206886566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2016 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6202521519 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COFFEYVILLE REGIONAL MEDICAL CENTER INC | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.