Provider Demographics
NPI:1932538535
Name:SPRING HILL FAMILY MEDICINE EXPRESS
Entity Type:Organization
Organization Name:SPRING HILL FAMILY MEDICINE EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-592-3000
Mailing Address - Street 1:22450 S HARRISON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRING HILL
Mailing Address - State:KS
Mailing Address - Zip Code:66083-3151
Mailing Address - Country:US
Mailing Address - Phone:913-592-2720
Mailing Address - Fax:913-592-2725
Practice Address - Street 1:22386 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:KS
Practice Address - Zip Code:66083-3148
Practice Address - Country:US
Practice Address - Phone:913-592-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS0430763261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS2003002200Medicaid
KS122467Medicare UPIN
KS2003002200Medicaid