Provider Demographics
NPI:1750325197
Name:NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
Entity Type:Organization
Organization Name:NORTHEAST KANSAS CENTER FOR HEALTH AND WELLNESS, INC.
Other - Org Name:PHYSICIAN HOSPITAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-486-2642
Mailing Address - Street 1:240 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:HORTON
Mailing Address - State:KS
Mailing Address - Zip Code:66439-1245
Mailing Address - Country:US
Mailing Address - Phone:785-486-2642
Mailing Address - Fax:785-486-2842
Practice Address - Street 1:240 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HORTON
Practice Address - State:KS
Practice Address - Zip Code:66439-1245
Practice Address - Country:US
Practice Address - Phone:785-486-2642
Practice Address - Fax:785-486-2842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH-007-002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS426980OtherBLUE SHIELD
KS161636OtherBLUE SHIELD
KS426996OtherBLUE SHIELD
KS664990OtherFIRST GUARD HEALTH PLAN
KS927587OtherFIRST GUARD HEALTH PLAN
KS928432OtherFIRST GUARD HEALTH PLAN
KS105445OtherBLUE SHIELD
KS042154OtherBLUE SHIELD
KS426996Medicare ID - Type Unspecified
KSP56504Medicare UPIN
KS042154Medicare ID - Type Unspecified
KS426980Medicare ID - Type Unspecified
KS161636OtherBLUE SHIELD
KS928432OtherFIRST GUARD HEALTH PLAN
KS426980OtherBLUE SHIELD
KS426996OtherBLUE SHIELD