Healthcare Provider Details

I. General information

NPI: 1093802456
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF MANHATTAN, P. A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 COLLEGE AVE SUITE G-210
MANHATTAN KS
66502-2770
US

IV. Provider business mailing address

1133 COLLEGE AVE SUITE G-210
MANHATTAN KS
66502-2770
US

V. Phone/Fax

Practice location:
  • Phone: 785-537-9030
  • Fax: 785-537-3334
Mailing address:
  • Phone: 785-537-9030
  • Fax: 785-537-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0000003920
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerBLUE SHIELD
# 2
Identifier100087970A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name: DOROTHY ANN TRUITT
Title or Position: OFFICE MANAGER
Credential:
Phone: 785-537-9030