1053639807 NPI number — PREFERRED MEDICAL ASSOCIATES

Table of content: (NPI 1053639807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053639807 NPI number — PREFERRED MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED MEDICAL ASSOCIATES
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:
6
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:
1053639807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14700 W. ST. TERESA
Provider Second Line Business Mailing Address:
STE. 370
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67235-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-796-7990
Provider Business Mailing Address Fax Number:
316-796-7999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14700 W. ST. TERESA
Provider Second Line Business Practice Location Address:
STE. 370
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67235-9600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-796-7990
Provider Business Practice Location Address Fax Number:
316-796-7999
Provider Enumeration Date:
05/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BETTIS
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
316-268-5266

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100087990E , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com