Basic Information
| Provider Information | |||||||||
| NPI: | 1265550891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COFFEYVILLE REGIONAL MEDICAL CENTER INC | ||||||||
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| 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: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6202521519 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COFFEYVILLE REGIONAL MEDICAL CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 110385 | 01 | KS | KS BCBS ER PROVIDER GROUP | OTHER | 100695360D | 05 | OK | MEDICAID | 100107200C | 05 | KS | MEDICAID |