Healthcare Provider Details

I. General information

NPI: 1184736563
Provider Name (Legal Business Name): SOUTHEAST KANSAS MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W 4TH ST
COFFEYVILLE KS
67337-3307
US

IV. Provider business mailing address

1501 W 4TH ST
COFFEYVILLE KS
67337-3307
US

V. Phone/Fax

Practice location:
  • Phone: 620-251-2400
  • Fax: 620-251-1619
Mailing address:
  • Phone: 620-251-2400
  • Fax: 620-251-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number44318
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0420630
License Number StateKS

VIII. Authorized Official

Name: JEROME BLOCK
Title or Position: OWNER
Credential: M.D.
Phone: 620-251-2400