Healthcare Provider Details

I. General information

NPI: 1467452904
Provider Name (Legal Business Name): JERZY SLOMKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N AYLWARD AVE
ELLSWORTH KS
67439-2541
US

IV. Provider business mailing address

1602 N AYLWARD AVE PO BOX 103
ELLSWORTH KS
67439-2541
US

V. Phone/Fax

Practice location:
  • Phone: 785-472-3111
  • Fax: 785-472-5731
Mailing address:
  • Phone: 785-472-3111
  • Fax: 785-472-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-25637
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-25637
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: