Basic Information
| Provider Information | |||||||||
| NPI: | 1184669947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISKO | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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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: | 1947 FOUNDERS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899227 | ||||||||
| FaxNumber: | 3166134940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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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 | 207Y00000X | 27721 | KS | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 11055 | 01 | KS | PHS | OTHER | 100188 | 01 | KS | HPK | OTHER | 053723 | 01 | KS | BCBS | OTHER | 12149472 | 01 | KS | MULTIPLAN | OTHER | 16961 | 01 | KS | COVENTRY | OTHER |