Healthcare Provider Details

I. General information

NPI: 1598902223
Provider Name (Legal Business Name): JERRY C BOUMAN DO PC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2009
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 S US HIGHWAY 59
PARSONS KS
67357-4948
US

IV. Provider business mailing address

1902 S HWY 59 BLDG D
PARSONS KS
67357-4955
US

V. Phone/Fax

Practice location:
  • Phone: 620-423-1606
  • Fax: 620-423-1668
Mailing address:
  • Phone: 620-423-1606
  • Fax: 620-423-1668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0524097
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JERRY CRAIG BOUMAN
Title or Position: OWNER
Credential: DO
Phone: 620-423-1606