Basic Information
Provider Information | |||||||||
NPI: | 1952585341 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KANSAS MEDICAL CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ANDOVER CARDIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 195 | ||||||||
Address2: |   | ||||||||
City: | SALINA | ||||||||
State: | KS | ||||||||
PostalCode: | 674020195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3163004021 | ||||||||
FaxNumber: | 9133810979 | ||||||||
Practice Location | |||||||||
Address1: | 1124 W 21ST ST | ||||||||
Address2: |   | ||||||||
City: | ANDOVER | ||||||||
State: | KS | ||||||||
PostalCode: | 670025500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3163004000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2007 | ||||||||
LastUpdateDate: | 05/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THORNTON | ||||||||
AuthorizedOfficialFirstName: | DARYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3163004021 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KANSAS MEDICAL CENTER, LLC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 200408390E | 05 | KS |   | MEDICAID | 111401 | 01 | KS | BCBSKS | OTHER |