MEDICARE: MICHAEL J SOUTHERN ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	46076	KS

General Provider Information

NPI Number	:	1265622864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J SOUTHERN ARNP

Provider Business Mailing Address
First Line	:	302 FLEMING ST STE 4
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6162
Country	:	US
Telephone Number	:	620-805-6939
Fax Number	:	620-805-6933

Provider Business Practice Location Address
First Line	:	302 FLEMING ST STE 4
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-6162
Country	:	US
Telephone Number	:	620-805-6939
Fax Number	:	620-805-6933

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	07/21/2015

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