Provider Demographics
NPI:1902899339
Name:WAMEGO HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:WAMEGO HOSPITAL ASSOCIATION
Other - Org Name:WAMEGO FAMILY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-456-2295
Mailing Address - Street 1:711 GENN DR
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-1179
Mailing Address - Country:US
Mailing Address - Phone:785-456-2295
Mailing Address - Fax:785-456-9467
Practice Address - Street 1:711 GENN DR
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547
Practice Address - Country:US
Practice Address - Phone:785-456-2295
Practice Address - Fax:785-456-9467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH-075-002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100420870BMedicaid
KS110789OtherBLUE CROSS
KS100420870CMedicaid
KS530895OtherPETERSEN-KS LICENSE #
KS0430151OtherDAREY-KS LICENSE#
KS44166OtherDOUGLAS-KS LICENSE#
KS001537OtherBLUE CROSS-RHC
KS110789Medicare ID - Type UnspecifiedPROVIDER #