Basic Information
| Provider Information | |||||||||
| NPI: | 1417939729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CENTRAL KANSAS ASSOCIATION INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RUSSELL REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676652920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833131 | ||||||||
| FaxNumber: | 7854834859 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676652920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7854833131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COURTOIS | ||||||||
| AuthorizedOfficialFirstName: | REGINALD | ||||||||
| AuthorizedOfficialMiddleName: | HAROLD | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR CEO | ||||||||
| AuthorizedOfficialTelephone: | 7854833131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H084001 | KS | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000076 | 01 | KS | BCBS | OTHER | 100306710A | 05 | KS | MEDICAID |