Basic Information
| Provider Information | |||||||||
| NPI: | 1801077672 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAWRENCE MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | MCLOUTH MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 MAINE ST | ||||||||
| Address2: | MSO, LIBRARY | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855052988 | ||||||||
| FaxNumber: | 7855053207 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 S UNION ST | ||||||||
| Address2: | |||||||||
| City: | MC LOUTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660544103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137966116 | ||||||||
| FaxNumber: | 9137962222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2007 | ||||||||
| LastUpdateDate: | 04/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CRED SPEC | ||||||||
| AuthorizedOfficialTelephone: | 9855052988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAWRENCE MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | 13-59692-09 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
No ID Information.