=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598868093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED PED CLINIC OF WICHITA PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 04/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9415 E HARRY ST SUITE 202
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-5089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-691-0309
-----------------------------------------------------
Fax | 316-691-0881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9415 E HARRY ST SUITE 202
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-5089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-691-0309
-----------------------------------------------------
Fax | 316-691-0881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SALEEM SHAHZAD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 316-691-0309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0429468
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------