Basic Information
| Provider Information | |||||||||
| NPI: | 1497730071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOB WILSON MEMORIAL GRANT COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ULYSSES FAMILY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ULYSSES | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678802135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203561261 | ||||||||
| FaxNumber: | 6203563846 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ULYSSES | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678802135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203561261 | ||||||||
| FaxNumber: | 6203563846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | KARLA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6203561261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KS | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100282430A | 05 | KS | MEDICAID | 110236 | 01 | KS | BC/BS | OTHER | 100282430B | 05 | KS | MEDICAID |