Healthcare Provider Details

I. General information

NPI: 1255335196
Provider Name (Legal Business Name): SUHAIL ANSARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2138 N KANSAS AVE
LIBERAL KS
67901-2012
US

IV. Provider business mailing address

PO BOX 69
LIBERAL KS
67905-0069
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-6222
  • Fax: 620-624-5413
Mailing address:
  • Phone: 620-624-6222
  • Fax: 620-624-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0428742
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: