Basic Information
| Provider Information | |||||||||
| NPI: | 1467564039 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY KANSAS COMMUNITIES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHERRYVALE FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 414 | ||||||||
| Address2: | 203 WEST MAIN STREET | ||||||||
| City: | CHERRYVALE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673350414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203362132 | ||||||||
| FaxNumber: | 6203362237 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHERRYVALE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673351332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203362132 | ||||||||
| FaxNumber: | 6203362237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/25/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4176252459 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1500335 | KS | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QR1300X | 1500335 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100089300I | 05 | KS | MEDICAID |