Healthcare Provider Details

I. General information

NPI: 1912969486
Provider Name (Legal Business Name): HILLSIDE MEDICAL OFFICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N HILLSIDE ST
WICHITA KS
67214-4913
US

IV. Provider business mailing address

855 N HILLSIDE ST
WICHITA KS
67214-4913
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-1381
  • Fax:
Mailing address:
  • Phone: 316-685-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. DAVID A GORDON
Title or Position: MANAGER
Credential: CPA
Phone: 316-685-1381