Provider Demographics
NPI:1609943042
Name:COFFEYVILLE REGIONAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:COFFEYVILLE REGIONAL MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-251-1200
Mailing Address - Street 1:1400 W 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3306
Mailing Address - Country:US
Mailing Address - Phone:620-251-1200
Mailing Address - Fax:620-252-1562
Practice Address - Street 1:1400 W 4TH ST FL 1
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-688-6561
Practice Address - Fax:620-688-8710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COFFEYVILLE REGIONAL MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-29
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA063006251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100107200DMedicaid
KS100107200DMedicaid