1306071303 NPI number — PREFERRED MEDICAL ASSOCIATES

Table of content: (NPI 1306071303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306071303 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:
1306071303
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
848 N SAINT FRANCIS ST
Provider Second Line Business Mailing Address:
STE. 2968
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67214-3800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-269-1717
Provider Business Mailing Address Fax Number:
316-291-7317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
848 N SAINT FRANCIS ST
Provider Second Line Business Practice Location Address:
STE. 2968
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67214-3800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-269-1717
Provider Business Practice Location Address Fax Number:
316-291-7317
Provider Enumeration Date:
05/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HETT
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
316-268-8080

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  04-33591 , 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: 100723300B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: PENDING , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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