Basic Information
| Provider Information | |||||||||
| NPI: | 1457314890 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KANSAS ORTHOPEDIC GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 K 96 HWY | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207924383 | ||||||||
| FaxNumber: | 6207922058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 K 96 HWY | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207924383 | ||||||||
| FaxNumber: | 6207922058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | FLESKE | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6207924383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | DA5837 | 01 | RR MC | OTHER |