Healthcare Provider Details

I. General information

NPI: 1699189043
Provider Name (Legal Business Name): PRAIRIE ENDOSCOPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12115 E 21ST ST N SUITE 107
WICHITA KS
67206-3567
US

IV. Provider business mailing address

12115 E 21ST ST N SUITE 107
WICHITA KS
67206-3567
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-7000
  • Fax: 316-440-7006
Mailing address:
  • Phone: 316-440-7000
  • Fax: 316-440-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number04-30240
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-30240
License Number StateKS

VIII. Authorized Official

Name: JEFFREY P DAVIS
Title or Position: SOLE OWNER
Credential: MD
Phone: 316-440-7000