1497730071 NPI number — BOB WILSON MEMORIAL GRANT COUNTY

Table of content: (NPI 1497730071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497730071 NPI number — BOB WILSON MEMORIAL GRANT COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOB WILSON MEMORIAL GRANT COUNTY
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:
ULYSSES FAMILY PHYSICIANS
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:
1497730071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ULYSSES
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67880-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-356-1261
Provider Business Mailing Address Fax Number:
620-356-3846

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ULYSSES
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67880-2135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-356-1261
Provider Business Practice Location Address Fax Number:
620-356-3846
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
KARLA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
620-356-1261

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , 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: 100282430A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110236 . This is a "BC/BS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100282430B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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