=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407880776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PHYSICIANS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 08/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 N CEDAR
-----------------------------------------------------
City | MORAN
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-237-4621
-----------------------------------------------------
Fax | 620-237-4402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 158
-----------------------------------------------------
City | MORAN
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66755-0158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-237-4621
-----------------------------------------------------
Fax | 620-237-4402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC TREAS
-----------------------------------------------------
Name | BRIAN D WOLFE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 620-237-4621
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------