Basic Information
| Provider Information | |||||||||
| NPI: | 1023110822 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIA CHRISTI CLINIC PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VIA CHRISTI CLINIC AUGUSTA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899102 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 W JOSEPHINE AVE | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670102037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167755432 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 12/19/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | SUZANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR,PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3166899617 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 5912199402 | 05 | KS | MEDICAID | 000933 | 01 | KS | BCBS | OTHER |