MEDICARE: MT. OREAD FAMILY PRACTICE

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	261QP2300X	Primary Care Clinic/Center	53-76993-042	KS

General Provider Information

NPI Number	:	1902271489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT. OREAD FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	3510 CLINTON PKWY
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66047-2145
Country	:	US
Telephone Number	:	785-842-5070
Fax Number	:	785-505-5096

Provider Business Practice Location Address
First Line	:	3510 CLINTON PKWY
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66047-2145
Country	:	US
Telephone Number	:	785-842-5070
Fax Number	:	785-505-5096

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	KELLY SUZANNE JIMENEZ
Credential	:	APRN
Telephone Number	:	785-842-5070

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	12/09/2015

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