Provider Demographics
NPI:1184691693
Name:GRACEMED HEALTH CLINIC INC
Entity type:Organization
Organization Name:GRACEMED HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VENUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-866-2064
Mailing Address - Street 1:1122 N TOPEKA
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2810
Mailing Address - Country:US
Mailing Address - Phone:316-866-2000
Mailing Address - Fax:316-866-2084
Practice Address - Street 1:1122 N TOPEKA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2810
Practice Address - Country:US
Practice Address - Phone:316-866-2000
Practice Address - Fax:316-866-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100212250AMedicaid
KS100212250AMedicaid
G24862Medicare UPIN
104025Medicare ID - Type UnspecifiedRAHUL SINGH
Q59169Medicare UPIN
426950Medicare ID - Type UnspecifiedGRETCHEN JONES
426730Medicare ID - Type UnspecifiedVIRGINIA RUNYAN
KS110238Medicare Oscar/Certification
KS171832Medicare Oscar/Certification
Q06435Medicare UPIN
Q23084Medicare UPIN
Q63019Medicare UPIN
Q61993Medicare UPIN
42909Medicare ID - Type UnspecifiedMAIHOA NGUYEN
KS171806Medicare ID - Type Unspecified
G67596Medicare UPIN
426949Medicare ID - Type UnspecifiedSARAH LINDSEY
KS171831Medicare Oscar/Certification
Q61994Medicare UPIN
42172Medicare ID - Type UnspecifiedJENNIFER EDISON
105270Medicare ID - Type UnspecifiedSUSAN GIOVANNI
KS110238Medicare PIN