1316952070 NPI number — PREFERRED MEDICAL ASSOCIATES

Table of content: (NPI 1316952070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316952070 NPI number — PREFERRED MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED MEDICAL ASSOCIATES
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:
D/B/A VCMA IOLA
Provider Other Organization Name Type Code:
3
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:
1316952070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 S WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOLA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66749-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-365-6933
Provider Business Mailing Address Fax Number:
620-365-8126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 S WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOLA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66749-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-365-6933
Provider Business Practice Location Address Fax Number:
620-365-8126
Provider Enumeration Date:
07/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HETT
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DO/MANAGING PARTNER
Authorized Official Telephone Number:
620-365-6933

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100088910 E , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".