MEDICARE: STATE OF KANSAS

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	283Q00000X	Psychiatric Hospital	M105001	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114920980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF KANSAS

Provider Business Mailing Address
First Line	:	500 STATE HOSPITAL DRIVE
Second Line	:
City	:	OSAWATOMIE
State	:	KS
Zip	:	66064-0500
Country	:	US
Telephone Number	:	913-755-7312
Fax Number	:	913-755-7127

Provider Business Practice Location Address
First Line	:	2205 WEST 36TH AVE
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66103-2198
Country	:	US
Telephone Number	:	913-789-5800
Fax Number	:	913-755-7127

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MR. STEVEN D. ASHCRAFT
Credential	:
Telephone Number	:	913-755-7073

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/30/2012

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Directions to “STATE OF KANSAS ” Practice Location

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