=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598091001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNFLOWER PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2009
-----------------------------------------------------
Last Update Date | 10/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2132 N. KANSAS AVE STE B
-----------------------------------------------------
City | LIBERAL
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-624-7400
-----------------------------------------------------
Fax | 620-624-7444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2132 N. KANSAS AVE., STE B
-----------------------------------------------------
City | LIBERAL
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-624-7400
-----------------------------------------------------
Fax | 620-624-7444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANAGER
-----------------------------------------------------
Name | MARIANA E LUCERO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 620-624-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0413614
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 04-28884
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------