Basic Information
| Provider Information | |||||||||
| NPI: | 1174879936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOMERS | ||||||||
| FirstName: | TYREL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 513 S KANSAS ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676653535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013011925 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 S KANSAS ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676653000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833333 | ||||||||
| FaxNumber: | 7854830781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RL12388 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12083 | 05 | ND | MEDICAID |