Basic Information
| Provider Information | |||||||||
| NPI: | 1598121790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILSON COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHERRYVALE FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 W MAIN ST | ||||||||
| Address2: | P.O. BOX 403 | ||||||||
| City: | CHERRYVALE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673351332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203362131 | ||||||||
| FaxNumber: | 6203362237 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHERRYVALE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673351332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203362131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2016 | ||||||||
| LastUpdateDate: | 02/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | GUTSCHENRITTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6203258388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WILSON COUNTY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.