Provider Demographics
NPI:1497730071
Name:BOB WILSON MEMORIAL GRANT COUNTY
Entity Type:Organization
Organization Name:BOB WILSON MEMORIAL GRANT COUNTY
Other - Org Name:ULYSSES FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-356-1261
Mailing Address - Street 1:505 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2135
Mailing Address - Country:US
Mailing Address - Phone:620-356-1261
Mailing Address - Fax:620-356-3846
Practice Address - Street 1:505 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2135
Practice Address - Country:US
Practice Address - Phone:620-356-1261
Practice Address - Fax:620-356-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100282430AMedicaid
KS110236OtherBC/BS
KS100282430BMedicaid
KS110236OtherBC/BS