Basic Information
| Provider Information | |||||||||
| NPI: | 1215905112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KANSAS TRAUMA AND CRITICAL CARE SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 47490 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672017490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169623150 | ||||||||
| FaxNumber: | 3169627334 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169623150 | ||||||||
| FaxNumber: | 3169627334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOLTON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3169623205 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 110906 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |