Basic Information
| Provider Information | |||||||||
| NPI: | 1801042353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL KANSAS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. JOSEPH FAMILY MEDICINE - GREAT BEND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3520 LAKIN AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207923767 | ||||||||
| FaxNumber: | 6207923767 | ||||||||
| Practice Location | |||||||||
| Address1: | 3520 LAKIN AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207923345 | ||||||||
| FaxNumber: | 6207923767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2008 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | IRSIK | ||||||||
| AuthorizedOfficialFirstName: | LEANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VP/SITE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6207866163 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100080680H | 05 | KS | MEDICAID |