1649720012 NPI number — E MEDICAL GROUP OF KANSAS NO. 5, LLC

Table of content: (NPI 1649720012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649720012 NPI number — E MEDICAL GROUP OF KANSAS NO. 5, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E MEDICAL GROUP OF KANSAS NO. 5, 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:
Provider Other Organization Name Type Code:
6
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:
1649720012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2301 FM 1187
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-469-6739
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 RUSSELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKEENEY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67672-2108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-743-2270
Provider Business Practice Location Address Fax Number:
785-743-2288
Provider Enumeration Date:
10/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
EDDINS
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD MEMBER
Authorized Official Telephone Number:
817-469-6739

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  A029013 , 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)





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