MEDICARE: CIMARRON PATHOLOGY PA

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	291U00000X	Clinical Medical Laboratory

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	690009229	OTHER		RAILROAD MEDICARE

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
3	130243	OTHER	KS	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629049648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CIMARRON PATHOLOGY PA

Provider Business Mailing Address
First Line	:	PO BOX 1699
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67201-1699
Country	:	US
Telephone Number	:	800-475-6236
Fax Number	:

Provider Business Practice Location Address
First Line	:	1436 N WESTERN AVE
Second Line	:
City	:	LIBERAL
State	:	KS
Zip	:	67901-2212
Country	:	US
Telephone Number	:	620-626-8500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HUBERT PETERSON
Credential	:	MD
Telephone Number	:	620-626-8500

Provider Enumeration Date	:	01/28/2006
Last Update Date	:	07/29/2013

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Directions to “CIMARRON PATHOLOGY PA ” Practice Location

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