=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003160987
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AHMAD QADDOUR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2012
-----------------------------------------------------
Last Update Date | 03/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 E 29TH ST N SUITE 310
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-858-9000
-----------------------------------------------------
Fax | 316-858-9005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9300 E 29TH ST N SUITE 310
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-858-9000
-----------------------------------------------------
Fax | 316-858-9005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 04-36484
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 04-36484
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------