Become a Provider

Name (first, M.I., last, maiden):


Board Certified: Yes or No?

Present address (number & street, city, state, zip):

Telephone (office):

Telephone (home):

Kansas License number:

Date issued:

Date expires:

Obstetrics: Yes No


Malpractice Insurance carrier :

Effective Date:

Expiration Date:

Time periods available for temporary coverage:


Time periods not available for temporary coverage:


List procedures performed:


List practice limitations:



Preferred e-mail address:
(please be specific, i.e:

How did you hear about Kansas Medical Resource? Please be specific.

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Last modified: Jul 14, 2014
For more information about "Becoming a Provider" or "Requesting Service" contact Andrea Ellis at 913-588-1228 or