Healthcare Provider Details

I. General information

NPI: 1083239412
Provider Name (Legal Business Name): KSPEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6446 E CENTRAL AVE STE 183
WICHITA KS
67206-1924
US

IV. Provider business mailing address

6446 E CENTRAL AVE STE 183
WICHITA KS
67206-1924
US

V. Phone/Fax

Practice location:
  • Phone: 316-516-2853
  • Fax:
Mailing address:
  • Phone: 316-516-2853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MUTHUKUMAR VELLAICHAMY
Title or Position: OWNER
Credential: MD
Phone: 316-516-2853