1508060864 NPI number — AUGUSTA FAMILY PRACTICE, PA

Table of content: (NPI 1508060864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508060864 NPI number — AUGUSTA FAMILY PRACTICE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUGUSTA FAMILY PRACTICE, PA
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:
1508060864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1306 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67010-1126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-775-9191
Provider Business Mailing Address Fax Number:
316-775-0348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-775-9191
Provider Business Practice Location Address Fax Number:
316-775-0348
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHEID
Authorized Official First Name:
LYNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC ADMINISTRATOR
Authorized Official Telephone Number:
316-201-6711

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  17D0970229 , 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: 100359330B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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