Provider Demographics
NPI:1811234818
Name:GREAT BEND REGIONAL HOSPITAL LLC
Entity Type:Organization
Organization Name:GREAT BEND REGIONAL HOSPITAL LLC
Other - Org Name:CENTRAL KANSAS FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-792-5341
Mailing Address - Street 1:1309 POLK
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530
Mailing Address - Country:US
Mailing Address - Phone:620-792-5341
Mailing Address - Fax:620-792-3702
Practice Address - Street 1:1309 POLK
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530
Practice Address - Country:US
Practice Address - Phone:620-792-5341
Practice Address - Fax:620-792-3702
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT BEND REGIONAL HOSPITAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-10
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100088870AMedicaid
KS173885Medicare Oscar/Certification