1699731034 NPI number — MR. REX L. WITTMAN P.A.

Table of content: KELLY ROBINSON (NPI 1710415096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699731034 NPI number — MR. REX L. WITTMAN P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITTMAN
Provider First Name:
REX
Provider Middle Name:
L.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
M

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:
1699731034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MEDICAL CENTER DRIVE
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67114-3765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-283-9977
Provider Business Mailing Address Fax Number:
316-283-0966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 S PINE ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67114-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-283-9977
Provider Business Practice Location Address Fax Number:
316-283-0966
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  15-00326 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 15-00326 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 111178028 . This is a "PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 970012263 . This is a "RR MEDICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 042442 . This is a "TRICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 042442 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 100287500C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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