Provider Demographics
NPI:1619372000
Name:ST ROSE HEALTH CENTER INC
Entity Type:Organization
Organization Name:ST ROSE HEALTH CENTER INC
Other - Org Name:GREAT BEND INTERNISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIRECTOR OF PHYSICIAN PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-623-2185
Mailing Address - Street 1:3515 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3633
Mailing Address - Country:US
Mailing Address - Phone:620-793-8429
Mailing Address - Fax:620-793-6014
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3633
Practice Address - Country:US
Practice Address - Phone:620-793-8429
Practice Address - Fax:620-793-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty