Basic Information
Provider Information | |||||||||
NPI: | 1457396236 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MORTENSEN | ||||||||
FirstName: | STEEN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8035 | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672080035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166899135 | ||||||||
FaxNumber: | 3166899102 | ||||||||
Practice Location | |||||||||
Address1: | 3311 E MURDOCK ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672083054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166899188 | ||||||||
FaxNumber: | 3166899140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 07/13/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 24511 | KS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 12149382 | 01 | KS | MULTIPLAN | OTHER | 200138 | 01 | KS | HPK | OTHER | 045150 | 01 | KS | BCBS | OTHER | 16910 | 01 | KS | COVENTRY | OTHER | 2585 | 01 | KS | PHS | OTHER |