Provider Demographics
NPI:1972507523
Name:COMMUNITY HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:COMMUNITY HOSPITAL ASSOCIATION
Other - Org Name:COMMUNITY HOSPITAL-FAIRFAX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:P
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-686-2320
Mailing Address - Street 1:102 S 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:TARKIO
Mailing Address - State:MO
Mailing Address - Zip Code:64491-1513
Mailing Address - Country:US
Mailing Address - Phone:660-736-4193
Mailing Address - Fax:660-736-4966
Practice Address - Street 1:102 S 6TH ST
Practice Address - Street 2:
Practice Address - City:TARKIO
Practice Address - State:MO
Practice Address - Zip Code:64491-1513
Practice Address - Country:US
Practice Address - Phone:660-736-4193
Practice Address - Fax:660-736-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27443017OtherBCBS KANSAS CITY MO
MO505180802Medicaid
MO505180802Medicaid
MOK620000Medicare ID - Type UnspecifiedKANSAS CITY MO/TOPEKA