Provider Demographics
NPI:1710988134
Name:CENTRAL KANSAS MEDICAL PARK ANCILLARY SERVICES, P.A.
Entity Type:Organization
Organization Name:CENTRAL KANSAS MEDICAL PARK ANCILLARY SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-793-5404
Mailing Address - Street 1:1309 POLK ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3618
Mailing Address - Country:US
Mailing Address - Phone:620-793-5404
Mailing Address - Fax:620-792-2665
Practice Address - Street 1:1309 POLK ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3618
Practice Address - Country:US
Practice Address - Phone:620-793-5404
Practice Address - Fax:620-792-2665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS016144OtherBLUE SHIELD
KS100245710AMedicaid
KS016144OtherBLUE SHIELD