Basic Information
| Provider Information | |||||||||
| NPI: | 1124347083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIBBE | ||||||||
| FirstName: | JOSHUA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 N TOPEKA ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168662000 | ||||||||
| FaxNumber: | 3168662084 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 S CLIFTON AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672163408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168662000 | ||||||||
| FaxNumber: | 3168662084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7365 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 50563 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201109370A | 05 | KS | MEDICAID |