Basic Information
| Provider Information | |||||||||
| NPI: | 1417169889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PROSTATE TREATMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 S CLIFTON AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672182913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162695000 | ||||||||
| FaxNumber: | 3162690404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 S CLIFTON AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672182913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162695000 | ||||||||
| FaxNumber: | 3162690404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANDSFIELD | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3162695000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0430440 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 111124 | 01 | KS | BCBS | OTHER |