Healthcare Provider Details

I. General information

NPI: 1740420520
Provider Name (Legal Business Name): PREMIER PHLEBOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2009
Last Update Date: 03/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N GREENWICH RD
WICHITA KS
67226-8269
US

IV. Provider business mailing address

PO BOX 47055
WICHITA KS
67201-7055
US

V. Phone/Fax

Practice location:
  • Phone: 316-617-5891
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL CHEATUM
Title or Position: PRESIDENT
Credential:
Phone: 316-617-5891