MEDICARE: KANSAS JOINT & SPINE INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KA2539	OTHER	KS	MEDICARE PTAN

General Provider Information

NPI Number	:	1164742565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KANSAS JOINT & SPINE INSTITUTE

Provider Business Mailing Address
First Line	:	10100 SHANNON WOODS ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67226-4103
Country	:	US
Telephone Number	:	316-858-1900
Fax Number	:	316-858-1905

Provider Business Practice Location Address
First Line	:	10100 SHANNON WOODS ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67226-4103
Country	:	US
Telephone Number	:	316-858-1900
Fax Number	:	316-858-1905

Authorized Official
Title or Position	:	CEO
Name	:	DEBBIE BROCK-BAKER
Credential	:
Telephone Number	:	316-858-1900

Provider Enumeration Date	:	06/08/2010
Last Update Date	:	11/16/2012

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Directions to “KANSAS JOINT & SPINE INSTITUTE ” Practice Location

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