Healthcare Provider Details

I. General information

NPI: 1013912088
Provider Name (Legal Business Name): COFFEY COUNTY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 PEARSON AVE
WAVERLY KS
66871-9676
US

IV. Provider business mailing address

PO BOX 289
BURLINGTON KS
66839-0289
US

V. Phone/Fax

Practice location:
  • Phone: 785-733-2667
  • Fax: 785-733-2143
Mailing address:
  • Phone: 620-364-5395
  • Fax: 620-364-8719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DEANNA WOLKEN
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 620-364-5395