1124111687 NPI number — MISSION MEDICAL GROUP OF KANSAS, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124111687 NPI number — MISSION MEDICAL GROUP OF KANSAS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSION MEDICAL GROUP OF KANSAS, PA
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:
1124111687
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:
45 M AIN STREET
Provider Second Line Business Mailing Address:
SUITE 408
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-662-4560
Provider Business Mailing Address Fax Number:
877-279-9425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2942B SW WANAMAKER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-662-4560
Provider Business Practice Location Address Fax Number:
877-279-9425
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GALLUP
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
866-662-4560

Provider Taxonomy Codes

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

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





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