Healthcare Provider Details

I. General information

NPI: 1588152607
Provider Name (Legal Business Name): MANUEL BROCKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 09/13/2025
Certification Date: 09/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 N RIVERVIEW ST STE 500
WICHITA KS
67203-4265
US

IV. Provider business mailing address

345 N RIVERVIEW ST STE 412
WICHITA KS
67203-4202
US

V. Phone/Fax

Practice location:
  • Phone: 316-616-1055
  • Fax: 855-633-0585
Mailing address:
  • Phone: 551-295-8223
  • Fax: 855-633-0585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40229
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-46674
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2021026162
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: