Basic Information
| Provider Information | |||||||||
| NPI: | 1285618991 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GALICHIA HEART HOSPITAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 N WOODLAWN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672202729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168582610 | ||||||||
| FaxNumber: | 3168582793 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 N WOODLAWN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672202729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168582610 | ||||||||
| FaxNumber: | 3168582793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3168582601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H087011 | KS | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100421720A | 05 | KS | MEDICAID |