Healthcare Provider Details

I. General information

NPI: 1730402645
Provider Name (Legal Business Name): KANSAS KIDS HEART CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015 E. CENTRAL SUITE 2
WICHITA KS
67206-1946
US

IV. Provider business mailing address

7015 E. CENTRAL SUITE 2
WICHITA KS
67206-1946
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-8800
  • Fax: 316-440-8802
Mailing address:
  • Phone: 316-440-8800
  • Fax: 316-440-8802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number04-32074
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number44567
License Number StateKS

VIII. Authorized Official

Name: DR. MOHAMAD K AL-AHDAB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 316-440-8800