Healthcare Provider Details

I. General information

NPI: 1306808092
Provider Name (Legal Business Name): CONNIE M MARSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N MINNEAPOLIS
WICHITA KS
67214-3124
US

IV. Provider business mailing address

1010 N KANSAS SUITE #3049
WICHITA KS
67214-3199
US

V. Phone/Fax

Practice location:
  • Phone: 316-293-2647
  • Fax: 316-293-1863
Mailing address:
  • Phone: 316-293-2647
  • Fax: 316-293-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0417613
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number0417613
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: