1023558541 NPI number — OTTAWA FAMILY PHYSICIANS, CHARTERED

Table of content: (NPI 1023558541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023558541 NPI number — OTTAWA FAMILY PHYSICIANS, CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OTTAWA FAMILY PHYSICIANS, CHARTERED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OTTAWA CARE CLINIC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023558541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1418 S MAIN ST
Provider Second Line Business Mailing Address:
STE 5
Provider Business Mailing Address City Name:
OTTAWA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66067-3543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-242-1620
Provider Business Mailing Address Fax Number:
785-242-5061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E 19TH ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-214-4903
Provider Business Practice Location Address Fax Number:
785-214-4622
Provider Enumeration Date:
03/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MCPHERON
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
785-242-1620

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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