Basic Information
Provider Information
NPI: 1609943042
EntityType: 2
ReplacementNPI:  
OrganizationName: COFFEYVILLE REGIONAL MEDICAL CENTER INC
LastName:  
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MiddleName:  
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Credential:  
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Mailing Information
Address1: 1400 W 4TH STREET
Address2:  
City: COFFEYVILLE
State: KS
PostalCode: 673373306
CountryCode: US
TelephoneNumber: 6202511200
FaxNumber: 6202521562
Practice Location
Address1: 908 SIGGINS ST
Address2:  
City: COFFEYVILLE
State: KS
PostalCode: 673372921
CountryCode: US
TelephoneNumber: 6206886561
FaxNumber: 6206888710
Other Information
ProviderEnumerationDate: 11/29/2006
LastUpdateDate: 07/21/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LAWRENCE
AuthorizedOfficialFirstName: BRIAN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 6202521519
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: COFFEYVILLE REGIONAL MEDICAL CENTER, INC
AuthorizedOfficialNamePrefix:  
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NPICertificationDate: 07/21/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251E00000XA063006KSY AgenciesHome Health 

ID Information
IDTypeStateIssuerDescription
100107200D05KS MEDICAID


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