Provider Demographics
NPI:1316916638
Name:FAMILY PRACTICE ASSOCIATES OF ULYSSES LLC
Entity type:Organization
Organization Name:FAMILY PRACTICE ASSOCIATES OF ULYSSES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:620-356-5870
Mailing Address - Street 1:202 W KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2034
Mailing Address - Country:US
Mailing Address - Phone:620-356-5870
Mailing Address - Fax:620-356-5867
Practice Address - Street 1:202 W KANSAS AVE
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2034
Practice Address - Country:US
Practice Address - Phone:620-356-5870
Practice Address - Fax:620-356-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-27920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100454690AMedicaid
KS100454690AMedicaid
KSF44933Medicare UPIN