Provider Demographics
NPI:1003809161
Name:SOUTHEAST KANSAS ORTHOPEDICS & SPORTS MEDICINE
Entity Type:Organization
Organization Name:SOUTHEAST KANSAS ORTHOPEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP OFFICER OWNER OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-431-0887
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:321 EAST MAIN
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720
Mailing Address - Country:US
Mailing Address - Phone:620-431-0887
Mailing Address - Fax:620-431-0816
Practice Address - Street 1:321 EAST MAIN
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720
Practice Address - Country:US
Practice Address - Phone:620-431-0887
Practice Address - Fax:620-431-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0520120207X00000X
207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
009839Medicare ID - Type Unspecified