Basic Information
| Provider Information | |||||||||
| NPI: | 1861673907 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREFERRED MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VCMA DIAGNOSTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 764 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672010764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162688123 | ||||||||
| FaxNumber: | 3162917716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 N AMIDON AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672032140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166871555 | ||||||||
| FaxNumber: | 3162914988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 03/19/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HETT | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3162688080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREFERRED MEDICAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 100088910R | 05 | KS | MEDICAID |