Healthcare Provider Details

I. General information

NPI: 1003164872
Provider Name (Legal Business Name): SEK PRIMARY CARE ASSOC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 OTTAWA RD SUITE 101
NEODESHA KS
66757-1897
US

IV. Provider business mailing address

2600 OTTAWA RD STE 101 PO BOX 345
NEODESHA KS
66757-1897
US

V. Phone/Fax

Practice location:
  • Phone: 620-325-2500
  • Fax: 620-325-2550
Mailing address:
  • Phone: 620-325-2500
  • Fax: 620-325-2550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-31846
License Number StateKS

VIII. Authorized Official

Name: AMY RENAE CUNNINGHAM
Title or Position: PRESIDENT
Credential: DO
Phone: 620-325-2500