Provider Demographics
NPI:1376625749
Name:MINNEOLA DISTRICT HOSPITAL NBR 2
Entity Type:Organization
Organization Name:MINNEOLA DISTRICT HOSPITAL NBR 2
Other - Org Name:DODGE CITY FAMILY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-885-4264
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:KS
Mailing Address - Zip Code:67865-0127
Mailing Address - Country:US
Mailing Address - Phone:620-885-4264
Mailing Address - Fax:620-885-4602
Practice Address - Street 1:200 W ROSS BLVD
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-7221
Practice Address - Country:US
Practice Address - Phone:620-371-7300
Practice Address - Fax:620-371-7304
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNEOLA DISTRICT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
KSH013002261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS000455OtherBLUE CROSS RHC
KS100010520BMedicaid
KS110486OtherBLUE SHIELD
KS100010520FMedicaid
KS110486OtherBLUE SHIELD