Basic Information
| Provider Information | |||||||||
| NPI: | 1982651824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOTROS | ||||||||
| FirstName: | MAGED | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685757 | ||||||||
| FaxNumber: | 3162687496 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685757 | ||||||||
| FaxNumber: | 3162687496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD15648 | RI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 04-29487 | KS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101810 | 01 | MEDICARE | OTHER | 100419770A | 05 | KS | MEDICAID |