1790720167 NPI number — ELDON K SUNDERLAND MD

Table of content: ELDON K SUNDERLAND MD (NPI 1790720167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790720167 NPI number — ELDON K SUNDERLAND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUNDERLAND
Provider First Name:
ELDON
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1790720167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8035
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67208-0035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-689-9135
Provider Business Mailing Address Fax Number:
316-689-9102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1947 FOUNDERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67206-3548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-689-9227
Provider Business Practice Location Address Fax Number:
316-858-2025
Provider Enumeration Date:
06/18/2006

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: 207Y00000X , with the licence number:  25465 , 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: 16944 . This is a "COVENTRY" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 200647 . This is a "HPK" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 4474 . This is a "PHS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 040842 . This is a "BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 12149428 . This is a "MULTIPLAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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