Basic Information
| Provider Information | |||||||||
| NPI: | 1669889978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INFECTIOUS DISEASE CONSULTANTS, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IDC PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 310 S HILLSIDE ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672112129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168331212 | ||||||||
| FaxNumber: | 3162640908 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 S HILLSIDE ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672112129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168331212 | ||||||||
| FaxNumber: | 3162640908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2014 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAGAN | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3168331212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INFECTIOUS DISEASE CONSULTANTS P.A. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | 2-13041 | KS | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X | 2-13041 | KS | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.