Basic Information
| Provider Information | |||||||||
| NPI: | 1467402040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KANSAS MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ST JOSEPH FAMILY MEDICINE/GREAT BEND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3520 LAKIN AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207923767 | ||||||||
| FaxNumber: | 6207923767 | ||||||||
| Practice Location | |||||||||
| Address1: | 3520 LAKIN AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207923345 | ||||||||
| FaxNumber: | 6207923767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6207866101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100080680D | 05 | KS | MEDICAID |