Basic Information
| Provider Information | |||||||||
| NPI: | 1881742807 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIAMI COUNTY MEDICAL CENTER INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIAMI COUNTY MEDICAL CENTER PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 BAPTISTE DR | ||||||||
| Address2: | |||||||||
| City: | PAOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660711314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132942327 | ||||||||
| FaxNumber: | 9132949897 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 BAPTISTE DR | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | PAOLA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660711314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132942327 | ||||||||
| FaxNumber: | 9132942167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | GRASSER | ||||||||
| AuthorizedOfficialFirstName: | TIERNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9137914461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIAMI COUNTY MEDICAL CENTER INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100026590B | 05 | KS | MEDICAID |