Healthcare Provider Details

I. General information

NPI: 1861437618
Provider Name (Legal Business Name): ELLIOT A MAGIDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 FOUNDERS ST
WICHITA KS
67206-3548
US

IV. Provider business mailing address

PO BOX 8035
WICHITA KS
67208-0035
US

V. Phone/Fax

Practice location:
  • Phone: 316-613-4625
  • Fax: 316-613-4628
Mailing address:
  • Phone: 316-689-9135
  • Fax: 316-689-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number17609
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: