Basic Information
| Provider Information | |||||||||
| NPI: | 1215907951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST CENTRAL KANSAS ASSOCIATION, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RUSSELL REGIONAL HOSPITAL PHYSICIANS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S MAIN ST BLDG B | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676652920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833131 | ||||||||
| FaxNumber: | 7854834859 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 S KANSAS ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676653000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833131 | ||||||||
| FaxNumber: | 7854834859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 04/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7854830708 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST CENTRAL KANSAS ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 171350A | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100306710B | 05 | KS | MEDICAID | 110498 | 01 | KS | BCBS | OTHER |