Basic Information
| Provider Information | |||||||||
| NPI: | 1346270915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRETSINGER | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BROCK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRETSINGER | ||||||||
| OtherFirstName: | W | ||||||||
| OtherMiddleName: | BROCK | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1301 W 12TH AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | EMPORIA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 668012589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203432900 | ||||||||
| FaxNumber: | 6203426520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W 12TH AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | EMPORIA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203432900 | ||||||||
| FaxNumber: | 6203426520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 19185 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100229490B | 05 | KS | MEDICAID |