Provider Demographics
NPI:1285681577
Name:PANACEA FAMILY MEDICINE, PA
Entity type:Organization
Organization Name:PANACEA FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:PARHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-432-5588
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-0843
Mailing Address - Country:US
Mailing Address - Phone:620-432-5588
Mailing Address - Fax:620-432-5593
Practice Address - Street 1:629 S PLUMMER AVE
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-1928
Practice Address - Country:US
Practice Address - Phone:620-432-5588
Practice Address - Fax:620-432-5593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS261QR1300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS111208OtherWPS MEDICARE GROUP NUMBER
KSDE1499OtherRR MEDICARE GROUP NUMBER
KS0000111208OtherBLUE CROSS GROUP
KS17-8977OtherRURAL HEALTH CLINIC PTAN