Basic Information
| Provider Information | |||||||||
| NPI: | 1144329061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COFFEYVILLE DOCTORS CLINIC P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 W 8TH ST | ||||||||
| Address2: | P O BOX 1057 | ||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673374109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202517500 | ||||||||
| FaxNumber: | 6202521715 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673374109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202517500 | ||||||||
| FaxNumber: | 6202521715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | LIN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6202517500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003973 | 01 | BLUE CROSS/BLUE SHIELD | OTHER | 100088520A | 05 | KS | MEDICAID | 100722430A | 05 | OK | MEDICAID |