Basic Information
| Provider Information | |||||||||
| NPI: | 1699750273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-CONTINENT ANESTHESIOLOGY CHARTERED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 47890 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672017890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166856112 | ||||||||
| FaxNumber: | 3166520340 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 N HILLSIDE ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672144910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167898444 | ||||||||
| FaxNumber: | 3166520340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | HOLDEMAN | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3167898444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CE7677 | 01 | KS | RAILROAD MEDICARE | OTHER | 100213090A | 05 | KS | MEDICAID | 004066 | 01 | KS | BCBS OF KANSAS | OTHER | 100722910A | 05 | OK | MEDICAID |