Basic Information
Provider Information | |||||||||
NPI: | 1699722900 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TALLGRASS GENERAL, VASCULAR & THORACIC SURGERY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6001 SW 6TH AVE | ||||||||
Address2: | SUITE 220 | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666151011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852320444 | ||||||||
FaxNumber: | 7852321562 | ||||||||
Practice Location | |||||||||
Address1: | 6001 SW 6TH AVE | ||||||||
Address2: | SUITE 220 | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666151011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852320444 | ||||||||
FaxNumber: | 7852321562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2006 | ||||||||
LastUpdateDate: | 04/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VANDERWIEDE | ||||||||
AuthorizedOfficialFirstName: | PAULA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7852320444 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | CN9836 | 01 | KS | RAILROAD MEDICARE | OTHER |