Provider Demographics
NPI:1144329061
Name:COFFEYVILLE DOCTORS CLINIC P A
Entity type:Organization
Organization Name:COFFEYVILLE DOCTORS CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-251-7500
Mailing Address - Street 1:801 W 8TH ST
Mailing Address - Street 2:P O BOX 1057
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-4109
Mailing Address - Country:US
Mailing Address - Phone:620-251-7500
Mailing Address - Fax:620-252-1715
Practice Address - Street 1:801 W 8TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-4109
Practice Address - Country:US
Practice Address - Phone:620-251-7500
Practice Address - Fax:620-252-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
003973OtherBLUE CROSS/BLUE SHIELD
KS100088520AMedicaid
OK100722430AMedicaid
OK100722430AMedicaid