Basic Information
| Provider Information | |||||||||
| NPI: | 1124023064 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL HEIGHTS MEDICAL CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W ROSS BLVD | ||||||||
| Address2: | STE 2A | ||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678017217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202273141 | ||||||||
| FaxNumber: | 6202278095 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 W ROSS BLVD | ||||||||
| Address2: | STE 2A | ||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678017217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202273141 | ||||||||
| FaxNumber: | 6202278095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SANDOVAL | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6202273141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100216110A | 05 | KS | MEDICAID |