Basic Information
| Provider Information | |||||||||
| NPI: | 1588632145 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESLEY MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | MID-KANSAS INPATIENT PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 3169622030 | ||||||||
| FaxNumber: | 3169623056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | CASTLEBERRY | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3169622055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100327110I | 05 | KS | MEDICAID | 110784 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |