MEDICARE: PRAIRIE STAR FAMILY PRACTICE, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	04-28262	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101898	OTHER	KS	BC/BS INDIVIDUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	110760	OTHER	KS	BC/BS GROUP
4	662541	OTHER	KS	FIRSTGUARD #

General Provider Information

NPI Number	:	1003929001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE STAR FAMILY PRACTICE, P.A.

Provider Business Mailing Address
First Line	:	1210 N. WASHINGTON, CLINIC B
Second Line	:	P.O. BOX 407
City	:	PLAINVILLE
State	:	KS
Zip	:	67663-0407
Country	:	US
Telephone Number	:	785-434-2622
Fax Number	:	785-434-2577

Provider Business Practice Location Address
First Line	:	1210 N. WASHINGTON, CLINIC B
Second Line	:
City	:	PLAINVILLE
State	:	KS
Zip	:	67663-1632
Country	:	US
Telephone Number	:	785-434-2622
Fax Number	:	785-434-2577

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	JENNIFER BRULL
Credential	:	M.D.
Telephone Number	:	785-434-2622

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	06/15/2010

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Directions to “PRAIRIE STAR FAMILY PRACTICE, P.A. ” Practice Location

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