Provider Demographics
NPI:1083689327
Name:COFFEYVILLE FAMILY PRACTICE CLINIC, P.A.
Entity Type:Organization
Organization Name:COFFEYVILLE FAMILY PRACTICE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-251-1100
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-0564
Mailing Address - Country:US
Mailing Address - Phone:620-251-1100
Mailing Address - Fax:620-251-7466
Practice Address - Street 1:209 W 7TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-4903
Practice Address - Country:US
Practice Address - Phone:620-251-1100
Practice Address - Fax:620-251-7466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100722460AOtherOKLAHOMA MEDICAID
KS100098700AMedicaid
KS009974OtherBLUE CROSS BLUE SHIELD
0344220001Medicare NSC
OK100722460AOtherOKLAHOMA MEDICAID