Healthcare Provider Details

I. General information

NPI: 1629049648
Provider Name (Legal Business Name): CIMARRON PATHOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1436 N WESTERN AVE
LIBERAL KS
67901-2212
US

IV. Provider business mailing address

PO BOX 1699
WICHITA KS
67201-1699
US

V. Phone/Fax

Practice location:
  • Phone: 620-626-8500
  • Fax:
Mailing address:
  • Phone: 800-475-6236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: HUBERT PETERSON
Title or Position: PRESIDENT
Credential: MD
Phone: 620-626-8500