Healthcare Provider Details

I. General information

NPI: 1083693634
Provider Name (Legal Business Name): ALY A GADALLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 04/01/2024
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1861 N ROCK RD STE 100
WICHITA KS
67206-1264
US

IV. Provider business mailing address

1861 N ROCK RD STE 100
WICHITA KS
67206-1264
US

V. Phone/Fax

Practice location:
  • Phone: 316-462-1070
  • Fax: 316-462-1078
Mailing address:
  • Phone: 316-462-1070
  • Fax: 316-462-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0429832
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-29832
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: