Basic Information
| Provider Information | |||||||||
| NPI: | 1629049648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CIMARRON PATHOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1699 | ||||||||
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| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672011699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004756236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1436 N WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679012212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206268500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | HUBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6206268500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 100757940A | 05 | OK | MEDICAID | 690009229 | 01 | RAILROAD MEDICARE | OTHER | 130243 | 01 | KS | BCBS | OTHER | 100328010A | 05 | KS | MEDICAID |