Healthcare Provider Details

I. General information

NPI: 1801863477
Provider Name (Legal Business Name): GERALD L WHITESIDE AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 W 6TH ST SUITE 100
LAWRENCE KS
66044-2249
US

IV. Provider business mailing address

1112 W 6TH ST SUITE 100
LAWRENCE KS
66044-2249
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-8479
  • Fax: 785-843-8481
Mailing address:
  • Phone: 785-843-8479
  • Fax: 785-843-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1252
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1983
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: