Basic Information
Provider Information | |||||||||
NPI: | 1699762559 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | METHODIST HOSPITAL ASSOCIATION INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 W FRONTVIEW ST | ||||||||
Address2: |   | ||||||||
City: | DODGE CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 678012213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202278551 | ||||||||
FaxNumber: | 6202258630 | ||||||||
Practice Location | |||||||||
Address1: | 510 W FRONTVIEW ST | ||||||||
Address2: |   | ||||||||
City: | DODGE CITY | ||||||||
State: | KS | ||||||||
PostalCode: | 678012213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202278551 | ||||||||
FaxNumber: | 6202258630 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2005 | ||||||||
LastUpdateDate: | 08/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANDS | ||||||||
AuthorizedOfficialFirstName: | TAMARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6202278551 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | N029001 | KS | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 314000000X | N029001 | KS | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 100108190A | 05 | KS |   | MEDICAID | 1278 | 01 | KS | BCBS KS | OTHER | 100009660B | 05 | KS |   | MEDICAID |