Basic Information
Provider Information | |||||||||
NPI: | 1124177191 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COFFEYVILLE REGIONAL MEDICAL CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 W 4TH STREET | ||||||||
Address2: |   | ||||||||
City: | COFFEYVILLE | ||||||||
State: | KS | ||||||||
PostalCode: | 673373306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202511200 | ||||||||
FaxNumber: | 6202521562 | ||||||||
Practice Location | |||||||||
Address1: | 1400 W 4TH STREET | ||||||||
Address2: |   | ||||||||
City: | COFFEYVILLE | ||||||||
State: | KS | ||||||||
PostalCode: | 67337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202511200 | ||||||||
FaxNumber: | 6202521562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2007 | ||||||||
LastUpdateDate: | 07/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAWRENCE | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6202521519 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 400 | KS | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 005571 | 01 | KS | BCBS | OTHER | 100695360B | 05 | OK |   | MEDICAID | 100107200G | 05 | KS |   | MEDICAID |