MEDICARE: COMMUNITY HEALTH CENTER OF SOUTHEAST KANSAS, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1851876163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY HEALTH CENTER OF SOUTHEAST KANSAS, INC.

Provider Business Mailing Address
First Line	:	3011 N MICHIGAN ST
Second Line	:
City	:	PITTSBURG
State	:	KS
Zip	:	66762-2546
Country	:	US
Telephone Number	:	620-231-9873
Fax Number	:	620-231-5062

Provider Business Practice Location Address
First Line	:	1624 S NATIONAL AVE
Second Line	:
City	:	FORT SCOTT
State	:	KS
Zip	:	66701-2645
Country	:	US
Telephone Number	:	620-231-9873
Fax Number	:

Authorized Official
Title or Position	:	GENERAL COUNSEL
Name	:	DANIEL SPENCER CREITZ
Credential	:
Telephone Number	:	620-240-5015

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	10/02/2018

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