Healthcare Provider Details

I. General information

NPI: 1306437579
Provider Name (Legal Business Name): BAILEY STAPLEMAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 W ROSS BLVD
DODGE CITY KS
67801-8425
US

IV. Provider business mailing address

DODGE CITY HIGH SCHOOL. 2201 W. ROSS BLVD
DODGE CITY KS
67801
US

V. Phone/Fax

Practice location:
  • Phone: 620-371-1023
  • Fax:
Mailing address:
  • Phone: 620-471-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number24-01516
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01516
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: