Basic Information
| Provider Information | |||||||||
| NPI: | 1922076918 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE COVENANT GROUP PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST JOHN HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10975 BENSON ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134694244 | ||||||||
| FaxNumber: | 9134691939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136806100 | ||||||||
| FaxNumber: | 9136806156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2007 | ||||||||
| NPIReactivationDate: | 05/25/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLCOMB | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9134694244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.