Basic Information
| Provider Information | |||||||||
| NPI: | 1013952126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPHTHALMIC ANESTHESIA TEAM PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 388 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671140388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162813700 | ||||||||
| FaxNumber: | 3162824322 | ||||||||
| Practice Location | |||||||||
| Address1: | 6100 EAST CENTRAL | ||||||||
| Address2: | STE 5 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166812020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | GERBERDING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | GENE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3166812020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 111237 | 01 | KS | BCBS | OTHER | 200376810A | 05 | KS | MEDICAID |