Basic Information
| Provider Information | |||||||||
| NPI: | 1891802914 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL KANSAS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST ROSE MEDICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3515 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3515 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | WEDDELL | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6207866643 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.