Basic Information
| Provider Information | |||||||||
| NPI: | 1942316799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHERIDAN COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOXIE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 826 18TH ST STE A | ||||||||
| Address2: | PO BOX 415 | ||||||||
| City: | HOXIE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 677404373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856753018 | ||||||||
| FaxNumber: | 7856752306 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 18TH ST STE A | ||||||||
| Address2: | BOX 415 | ||||||||
| City: | HOXIE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 677404373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856753018 | ||||||||
| FaxNumber: | 7856752306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FARBER | ||||||||
| AuthorizedOfficialFirstName: | NICETA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7856753281 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHERIDAN COUNTY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 110255 | 01 | KS | BLUE CROSS | OTHER | 100009640B | 05 | KS | MEDICAID | 1188 | 01 | KS | BLUE CROSS RHC | OTHER |