1457710790 NPI number — JEFFERSON COUNTY MEMORIAL HOSPITAL

Table of content: (NPI 1457710790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457710790 NPI number — JEFFERSON COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON COUNTY MEMORIAL HOSPITAL
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:
1457710790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 DELAWARE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66097-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-774-4340
Provider Business Mailing Address Fax Number:
913-774-3379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15630 PINEHURST DR
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
BASEHOR
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66007-8233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-662-7042
Provider Business Practice Location Address Fax Number:
913-662-7046
Provider Enumeration Date:
02/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
LAMONT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
913-774-4340

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  H044001 , 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: 100080370F , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110046 . This is a "MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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