Healthcare Provider Details

I. General information

NPI: 1154535060
Provider Name (Legal Business Name): MIDWEST PSYCHIATRIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 W 94TH TER STE 200
PRAIRIE VILLAGE KS
66207-2536
US

IV. Provider business mailing address

5300 W 94TH TER STE 200
PRAIRIE VILLAGE KS
66207-2536
US

V. Phone/Fax

Practice location:
  • Phone: 913-381-8555
  • Fax: 913-677-2112
Mailing address:
  • Phone: 913-381-8555
  • Fax: 913-677-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number0427007
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0427007
License Number StateKS

VIII. Authorized Official

Name: MAGDALEN GUSTILO
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 714-568-7667