Basic Information
| Provider Information | |||||||||
| NPI: | 1477518934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 47490 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672017490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169623150 | ||||||||
| FaxNumber: | 3169627334 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169623150 | ||||||||
| FaxNumber: | 3169627334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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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 | 207R00000X | 04-29130 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 04-29130 | KS | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 103059 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 411471 | 01 | KS | FIRSTGUARD | OTHER | 100397190B | 05 | KS | MEDICAID | 203466 | 01 | KS | HEALTH PARTNERS OF KANSAS | OTHER |