1912963067 NPI number — SPECTRUM FAMILY MEDICAL CLINIC, PA

Table of content: (NPI 1912963067)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912963067 NPI number — SPECTRUM FAMILY MEDICAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM FAMILY MEDICAL CLINIC, 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:
1912963067
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 N TYLER
Provider Second Line Business Mailing Address:
STE 114
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67212-4916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 N TYLER
Provider Second Line Business Practice Location Address:
STE 114
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67212-4916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-462-0460
Provider Business Practice Location Address Fax Number:
316-462-0465
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANN
Authorized Official First Name:
PHAEDRA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
316-462-0460

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0422366 , 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: 100112800C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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