=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558329508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POGGI PLASTIC SURGERY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 02/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3510 N. RIDGE ROAD SUITE 100
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-269-3223
-----------------------------------------------------
Fax | 316-269-3328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3510 N. RIDGE ROAD SUITE 100
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-269-3223
-----------------------------------------------------
Fax | 316-269-3328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. JOSEPH T POGGI III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 316-269-3223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 04-29591
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | 04-29591
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------