Healthcare Provider Details

I. General information

NPI: 1790280360
Provider Name (Legal Business Name): GEOFFREY ANDREW BOISVERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3243 E MURDOCK ST STE 404
WICHITA KS
67208-3007
US

IV. Provider business mailing address

424 N RUTAN ST
WICHITA KS
67208-3217
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-6222
  • Fax:
Mailing address:
  • Phone: 864-567-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0450020
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0450020
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: