Healthcare Provider Details

I. General information

NPI: 1497829261
Provider Name (Legal Business Name): OHAEBOSIM MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 E 21ST STREET
WICHITA KS
67214-2252
US

IV. Provider business mailing address

2810 E 21ST STREET
WICHITA KS
67214-2252
US

V. Phone/Fax

Practice location:
  • Phone: 316-681-1901
  • Fax: 316-618-7362
Mailing address:
  • Phone: 316-681-1901
  • Fax: 316-618-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0516911
License Number StateKS

VIII. Authorized Official

Name: DR. LINUS C OHAEBOSIM
Title or Position: OWNER PRESIDENT
Credential: DO
Phone: 316-681-1901