Provider Demographics
NPI:1831287291
Name:MEDICINE LODGE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEDICINE LODGE MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-886-3771
Mailing Address - Street 1:710 N. WALNUT ST.
Mailing Address - Street 2:DRAWER 'C'
Mailing Address - City:MEDICINE LODGE
Mailing Address - State:KS
Mailing Address - Zip Code:67104-1019
Mailing Address - Country:US
Mailing Address - Phone:620-886-3771
Mailing Address - Fax:620-886-5012
Practice Address - Street 1:710 N. WALNUT ST.
Practice Address - Street 2:DRAWER 'C'
Practice Address - City:MEDICINE LODGE
Practice Address - State:KS
Practice Address - Zip Code:67104-1019
Practice Address - Country:US
Practice Address - Phone:620-886-3771
Practice Address - Fax:620-886-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSHS004002367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS171334Medicare ID - Type UnspecifiedCRNA BILLING #