1336231232 NPI number — DODGE CITY HEALTHCARE GROUP LLC

Table of content: (NPI 1336231232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336231232 NPI number — DODGE CITY HEALTHCARE GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DODGE CITY HEALTHCARE GROUP LLC
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:
WESTERN PLAINS MEDICAL COMPLEX
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:
1336231232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 AVENUE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-2270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-225-8401
Provider Business Practice Location Address Fax Number:
620-225-8403
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DILLON
Authorized Official First Name:
TERRANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
502-596-7220

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  H029002 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110037 . This is a "BC PROFESSIONAL FEES" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 634280 . This is a "FIRST GUARD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 000555 . This is a "BLUE CROSS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 10009879B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100098790A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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