Basic Information
| Provider Information | |||||||||
| NPI: | 1841600095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FULTON MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | FULTON MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11221 ROE AVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662111922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133870510 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 N HOSPITAL DR | ||||||||
| Address2: | SUITE F | ||||||||
| City: | FULTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652512535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736425338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | TASSET | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE CHAIR, NUEHEALTH | ||||||||
| AuthorizedOfficialTelephone: | 9133870510 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.