=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922076918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE COVENANT GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 S 4TH ST
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-680-6100
-----------------------------------------------------
Fax | 913-680-6156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10975 BENSON ST
-----------------------------------------------------
City | OVERLAND PARK
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66210-2133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-469-4244
-----------------------------------------------------
Fax | 913-469-1939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. MARK S HOLCOMB
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 913-469-4244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------