Basic Information
| Provider Information | |||||||||
| NPI: | 1801007786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANSAS MEDICAL CENTER, LLC | ||||||||
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| OtherOrganizationName: | KMC PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268938 | ||||||||
| Address2: | DEPARTMENT 96 0511 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004021 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 W. 21ST ST | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004000 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | THORNTON | ||||||||
| AuthorizedOfficialFirstName: | DARYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3163004021 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KANSAS MEDICAL CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KS | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207PE0004X | KS | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | DN3967 | 01 | KS | RR MEDICARE | OTHER | 111283 | 01 | KS | BSBSKS | OTHER | 200408390B | 05 | KS | MEDICAID |