Provider Demographics
NPI:1801042353
Name:CENTRAL KANSAS MEDICAL CENTER
Entity Type:Organization
Organization Name:CENTRAL KANSAS MEDICAL CENTER
Other - Org Name:ST. JOSEPH FAMILY MEDICINE - GREAT BEND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP/SITE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:IRSIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-786-6163
Mailing Address - Street 1:3520 LAKIN AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3646
Mailing Address - Country:US
Mailing Address - Phone:620-792-3767
Mailing Address - Fax:620-792-3767
Practice Address - Street 1:3520 LAKIN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3646
Practice Address - Country:US
Practice Address - Phone:620-792-3345
Practice Address - Fax:620-792-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-15
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100080680HMedicaid
KS703801Medicare Oscar/Certification