MEDICARE: WICHITA FOOT AND ANKLE WOUND CENTER

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	213ES0103X	Foot & Ankle Surgery Podiatrist

General Provider Information

NPI Number	:	1750752960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICHITA FOOT AND ANKLE WOUND CENTER

Provider Business Mailing Address
First Line	:	2522 N GRAYSTONE CIR
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67228-8039
Country	:	US
Telephone Number	:	316-755-8004
Fax Number	:	316-652-9913

Provider Business Practice Location Address
First Line	:	220 S HILLSIDE ST STE B
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67211-2151
Country	:	US
Telephone Number	:	316-755-8004
Fax Number	:	316-652-9913

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER SURTMAN
Credential	:	DPM
Telephone Number	:	316-755-8004

Provider Enumeration Date	:	10/14/2015
Last Update Date	:	08/16/2016

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