Basic Information
Provider Information | |||||||||
NPI: | 1164747598 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAWRENCE MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 325 MAINE ST | ||||||||
Address2: | MSO, LIBRARY | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 66044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7855052988 | ||||||||
FaxNumber: | 7855053207 | ||||||||
Practice Location | |||||||||
Address1: | 1130 W 4TH ST | ||||||||
Address2: | SUITE 2051 | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 660441328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7858568346 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2010 | ||||||||
LastUpdateDate: | 04/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | CRED SPEC | ||||||||
AuthorizedOfficialTelephone: | 7855052988 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LAWRENCE VEIN CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 20121 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.