Basic Information
| Provider Information | |||||||||
| NPI: | 1326076977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-KANSAS WOUND SPECIALIST P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801660 | ||||||||
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| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641800001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007000278 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE ST | ||||||||
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| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168622239 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 04/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3169622239 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | CI6093 | 01 | KS | RAILROAD MEDICARE | OTHER | 110380 | 01 | KS | BLUE CROSS GROUP # | OTHER |