1063453959 NPI number — HILLSIDE MEDICAL GROUP, P.A.

Table of content: (NPI 1063453959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063453959 NPI number — HILLSIDE MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HILLSIDE MEDICAL GROUP, P.A.
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:
1063453959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 E 9TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINFIELD
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67156-3220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-221-0110
Provider Business Mailing Address Fax Number:
620-221-0623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 E 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINFIELD
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67156-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-221-0110
Provider Business Practice Location Address Fax Number:
620-221-0623
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BIRD
Authorized Official First Name:
ALVIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
620-221-0110

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110252 . This is a "BC/BS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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