Provider Demographics
NPI:1598902223
Name:JERRY C BOUMAN DO PC INC
Entity Type:Organization
Organization Name:JERRY C BOUMAN DO PC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:BOUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-423-1606
Mailing Address - Street 1:1902 S HWY 59 BLDG D
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-4955
Mailing Address - Country:US
Mailing Address - Phone:620-423-1606
Mailing Address - Fax:620-423-1668
Practice Address - Street 1:1902 S US HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:KS
Practice Address - Zip Code:67357-4948
Practice Address - Country:US
Practice Address - Phone:620-423-1606
Practice Address - Fax:620-423-1668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0524097261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical