Basic Information
| Provider Information | |||||||||
| NPI: | 1992733539 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPITAL DISTRICT NO 1 CRAWFORD COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GIRARD MEDICAL CENTER OF FRONTENAC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1011 N HIGHWAY 69 | ||||||||
| Address2: | |||||||||
| City: | FRONTENAC | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667638100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202351377 | ||||||||
| FaxNumber: | 6202351558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N HIGHWAY 69 | ||||||||
| Address2: | |||||||||
| City: | FRONTENAC | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667638100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202351377 | ||||||||
| FaxNumber: | 6202351558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6207248291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOSPITAL DISTRICT NO 1 CRAWFORD COUNTY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | H-019-001 | KS | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100004200N | 05 | KS | MEDICAID |