Basic Information
Provider Information | |||||||||
NPI: | 1144770298 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LINDSBORG COMMUNITY HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LINDSBORG COMMUNITY HOSPITAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 605 W LINCOLN ST | ||||||||
Address2: |   | ||||||||
City: | LINDSBORG | ||||||||
State: | KS | ||||||||
PostalCode: | 674562328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852273308 | ||||||||
FaxNumber: | 7852274130 | ||||||||
Practice Location | |||||||||
Address1: | 3715 10TH ST | ||||||||
Address2: |   | ||||||||
City: | GREAT BEND | ||||||||
State: | KS | ||||||||
PostalCode: | 675303542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6207927868 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2016 | ||||||||
LastUpdateDate: | 01/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VAN DER WEGE | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7852273308 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LINDSBORG COMMUNITY HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | H-059-001 | KS | N |   | Hospitals | General Acute Care Hospital | Critical Access | 207Q00000X | H-059-001 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 016774 | 01 | KS | MEDICARE ID - TYPE UNSPECIFIED | OTHER |