Provider Demographics
NPI:1083702369
Name:MEDICINE LODGE MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:MEDICINE LODGE MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-886-3771
Mailing Address - Street 1:710 N. WALNUT ST.
Mailing Address - Street 2:DRAWERE 'C'
Mailing Address - City:MEDICINE LODGE
Mailing Address - State:KS
Mailing Address - Zip Code:67104-1019
Mailing Address - Country:US
Mailing Address - Phone:620-930-3744
Mailing Address - Fax:620-930-3784
Practice Address - Street 1:710 N. WALNUT ST.
Practice Address - Street 2:DRAWER 'C'
Practice Address - City:MEDICINE LODGE
Practice Address - State:KS
Practice Address - Zip Code:67104-1019
Practice Address - Country:US
Practice Address - Phone:620-930-3744
Practice Address - Fax:620-930-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSH004002261QR1300X
KSHS004002261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100092110BMedicaid
KS178545Medicare ID - Type UnspecifiedRHC PROVIDER #
KS100092110BMedicaid
KS110397Medicare ID - Type UnspecifiedCLINIC BILLING #