Basic Information
Provider Information | |||||||||
NPI: | 1316973860 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KANSAS LONG TERM CARE PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 155 N MARKET ST | ||||||||
Address2: | SUITE 950 | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672021816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3162695000 | ||||||||
FaxNumber: | 3162690404 | ||||||||
Practice Location | |||||||||
Address1: | 1315 N WEST ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672031382 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3169431295 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 11/20/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DENNE | ||||||||
AuthorizedOfficialFirstName: | GEORGIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3162695000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 111216 | 01 | KS | BCBS | OTHER | DE4553 | 01 | KS | RAIL ROAD MEDICARE | OTHER |