Basic Information
| Provider Information | |||||||||
| NPI: | 1356012181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADDICTION TOXICOLOGY OF KANSAS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1518 E KALISPELL CT | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670027982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528645790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 E HARRY ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672183713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2021 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAYNES | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | M R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2528645790 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PT0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207RA0401X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.