Basic Information
| Provider Information | |||||||||
| NPI: | 1619934312 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL SURGICAL ASSOCIATES, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3520 LAKIN AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207921227 | ||||||||
| FaxNumber: | 6207928029 | ||||||||
| Practice Location | |||||||||
| Address1: | 3520 LAKIN AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207921227 | ||||||||
| FaxNumber: | 6207928029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIRBY | ||||||||
| AuthorizedOfficialFirstName: | MERLIN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6207921227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016622 | 01 | KS | BLUE CROSS & BLUE SHIELD | OTHER |