Basic Information
Provider Information | |||||||||
NPI: | 1306027446 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREFERRED MEDICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VCMA WEST 21ST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 764 | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672010764 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3162688123 | ||||||||
FaxNumber: | 3162917716 | ||||||||
Practice Location | |||||||||
Address1: | 8444 W 21ST ST N | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672051752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3167219500 | ||||||||
FaxNumber: | 3167219574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2007 | ||||||||
LastUpdateDate: | 07/14/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HETT | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3162688080 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PREFERRED MEDICAL ASSOCIATES | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100003230S | 05 | KS |   | MEDICAID | 100088910I | 05 | KS |   | MEDICAID |