Provider Demographics
NPI:1922003995
Name:COFFEY COUNTY MEDICAL CENTER
Entity Type:Organization
Organization Name:COFFEY COUNTY MEDICAL CENTER
Other - Org Name:GRIDLEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-364-5395
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-0289
Mailing Address - Country:US
Mailing Address - Phone:620-364-5395
Mailing Address - Fax:620-364-8719
Practice Address - Street 1:321 ATHERLY
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:KS
Practice Address - Zip Code:66852
Practice Address - Country:US
Practice Address - Phone:620-836-2915
Practice Address - Fax:620-836-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2022-07-21
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
22462Medicare ID - Type Unspecified