1861503849 NPI number — ADVANCED SURGICAL WEIGHT LOSS, CHARTERED

Table of content: (NPI 1861503849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861503849 NPI number — ADVANCED SURGICAL WEIGHT LOSS, CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SURGICAL WEIGHT LOSS, CHARTERED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861503849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 W 15TH ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LIBERAL
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67901-2467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-626-6448
Provider Business Mailing Address Fax Number:
620-626-7040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 W 15TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LIBERAL
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67901-2467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-626-6448
Provider Business Practice Location Address Fax Number:
620-626-7040
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANFIELD
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
620-626-6448

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  04-27942 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103579 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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