Basic Information
| Provider Information | |||||||||
| NPI: | 1427026384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLENWATER | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 48037 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672018037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166856112 | ||||||||
| FaxNumber: | 3166520340 | ||||||||
| Practice Location | |||||||||
| Address1: | 3515 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675303633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207922511 | ||||||||
| FaxNumber: | 3166520340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0421903 | KS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LA0401X | 0421903 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207LC0200X | 0421903 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP2900X | 0421903 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 045282 | 01 | KS | BCBS | OTHER | 050022332 | 01 | RAILROAD MEDICARE | OTHER | 100142910A | 05 | KS | MEDICAID | 481129529 | 01 | TRICARE | OTHER |