Provider Demographics
NPI:1982764981
Name:CENTER FOR ADVANCED GYNECOLOGY REVOCABLE TRUST
Entity Type:Organization
Organization Name:CENTER FOR ADVANCED GYNECOLOGY REVOCABLE TRUST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOCUM
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:785-354-9591
Mailing Address - Street 1:823 SW MULVANE ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1764
Mailing Address - Country:US
Mailing Address - Phone:785-270-8070
Mailing Address - Fax:785-270-8071
Practice Address - Street 1:823 SW MULVANE ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1764
Practice Address - Country:US
Practice Address - Phone:785-270-8070
Practice Address - Fax:785-270-8071
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COTTON-O'NEIL CLINIC REVOCABLE TRUST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200302660AMedicaid
KS111047Medicare PIN