Provider Demographics
NPI:1629049648
Name:CIMARRON PATHOLOGY PA
Entity Type:Organization
Organization Name:CIMARRON PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HUBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-626-8500
Mailing Address - Street 1:PO BOX 1699
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1699
Mailing Address - Country:US
Mailing Address - Phone:800-475-6236
Mailing Address - Fax:
Practice Address - Street 1:1436 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2212
Practice Address - Country:US
Practice Address - Phone:620-626-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-28
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100757940AMedicaid
690009229OtherRAILROAD MEDICARE
KS130243OtherBCBS
KS100328010AMedicaid
KS130243OtherBCBS
KS100328010AMedicaid