Provider Demographics
NPI:1609872456
Name:HURLEY, DOMINIC VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:VINCENT
Last Name:HURLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-2504
Mailing Address - Country:US
Mailing Address - Phone:620-343-6800
Mailing Address - Fax:
Practice Address - Street 1:1301 W 12TH AVE STE 207
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801
Practice Address - Country:US
Practice Address - Phone:620-342-4278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27785207RC0000X, 207RI0011X
SD1974207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD060057374OtherRAILROAD MEDICARE
IA07224OtherBCBS
IA1955518Medicaid
MN19D71HUOtherBCBS
SD6001954Medicaid
SD0006095OtherBCBS
IA060063694OtherRAILROAD MEDICARE
MN546090500Medicaid
IAI4824Medicare ID - Type Unspecified
SDS6095Medicare PIN
IA07224OtherBCBS