Provider Demographics
NPI:1629252366
Name:ST MARYS FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:ST MARYS FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:785-437-2105
Mailing Address - Street 1:515 W BERTRAND AVE
Mailing Address - Street 2:P.O. BOX 56
Mailing Address - City:SAINT MARYS
Mailing Address - State:KS
Mailing Address - Zip Code:66536-1618
Mailing Address - Country:US
Mailing Address - Phone:785-437-2105
Mailing Address - Fax:785-437-2104
Practice Address - Street 1:515 W BERTRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:KS
Practice Address - Zip Code:66536-1618
Practice Address - Country:US
Practice Address - Phone:785-437-2105
Practice Address - Fax:785-437-2104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21765261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
B69318Medicare UPIN