Healthcare Provider Details

I. General information

NPI: 1992272918
Provider Name (Legal Business Name): UKHS GREAT BEND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

IV. Provider business mailing address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

V. Phone/Fax

Practice location:
  • Phone: 620-786-6163
  • Fax: 620-786-6298
Mailing address:
  • Phone: 620-786-6163
  • Fax: 620-786-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSE MOCK
Title or Position: CEO
Credential:
Phone: 620-791-6272