Healthcare Provider Details

I. General information

NPI: 1245617646
Provider Name (Legal Business Name): AVALON ADVANCED HEALTH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W 27TH ST SUITE F4
HAYS KS
67601-4823
US

IV. Provider business mailing address

1011 W 27TH ST SUITE F4
HAYS KS
67601-4823
US

V. Phone/Fax

Practice location:
  • Phone: 785-301-2639
  • Fax:
Mailing address:
  • Phone: 785-301-2639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number05-32944
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number05-32944
License Number StateKS

VIII. Authorized Official

Name: DR. MARSHALL EIDENBERG
Title or Position: VICE PRESIDENT/CMO
Credential: D.O.
Phone: 785-301-2639