Provider Demographics
NPI:1780922773
Name:GREAT BEND REGIONAL HOSPITAL, LLC
Entity type:Organization
Organization Name:GREAT BEND REGIONAL HOSPITAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-792-5341
Mailing Address - Street 1:1309 POLK ST
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:620-792-5404
Mailing Address - Fax:620-792-2665
Practice Address - Street 1:1309 POLK ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3644
Practice Address - Country:US
Practice Address - Phone:620-792-4266
Practice Address - Fax:620-792-2665
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT BEND REGIONAL HOSPITAL, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-25
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1060622085R0202X
KS17D0452731291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
016134Medicare UPIN