Basic Information
| Provider Information | |||||||||
| NPI: | 1376539502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIA CHRISTI HOSPITALS WICHITA, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VIA CHRISTI CHANG FAMILY MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1897 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672011897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162688131 | ||||||||
| FaxNumber: | 3162914788 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 N EMPORIA ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168583460 | ||||||||
| FaxNumber: | 3168583458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | LABARCA | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3162685161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VIA CHRISTI HOSPITALS WICHITA, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 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 | 100080640D | 05 | KS | MEDICAID |