Basic Information
| Provider Information | |||||||||
| NPI: | 1295284842 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COFFEYVILLE REGIONAL MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRMC MEDICAL GROUP - INDEPENDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202511200 | ||||||||
| FaxNumber: | 6202521181 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 W MYRTLE ST LOWR LEVEL | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673013317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6205774062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2016 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6202521519 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COFFEYVILLE REGIONAL MEDICAL CENTER, INC. | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.