Provider Demographics
NPI:1619955853
Name:GREAT BEND CHILDRENS CLINIC PA
Entity Type:Organization
Organization Name:GREAT BEND CHILDRENS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-792-5437
Mailing Address - Street 1:1021 EISENHOWER AVE
Mailing Address - Street 2:GREAT BEND CHILDREN'S CLINIC
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3213
Mailing Address - Country:US
Mailing Address - Phone:620-792-5437
Mailing Address - Fax:620-793-5245
Practice Address - Street 1:1021 EISENHOWER AVE
Practice Address - Street 2:GREAT BEND CHILDREN'S CLINIC
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3213
Practice Address - Country:US
Practice Address - Phone:620-792-5437
Practice Address - Fax:620-793-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100127410BMedicaid
KS100299730AMedicaid
KS016773OtherBCBS GROUP NO