Basic Information
| Provider Information | |||||||||
| NPI: | 1477692051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIA CHRISTI IMMEDIATE CARE, MOTHER MARY ANNE INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VIA CHRISTI MOTHER MARY ANNE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1152 S. CLIFTON | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672182913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166895121 | ||||||||
| FaxNumber: | 3166895122 | ||||||||
| Practice Location | |||||||||
| Address1: | 1152 S. CLIFTON | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672182913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166895121 | ||||||||
| FaxNumber: | 3166895122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BETTIS | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3162685266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | KS | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 200452390A | 05 | KS | MEDICAID |