=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720445950
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFORMANCE HEALTH, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2016
-----------------------------------------------------
Last Update Date | 01/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10111 E 21ST ST N STE 315
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-3581
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-260-9005
-----------------------------------------------------
Fax | 316-260-9019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4342 N RUSHWOOD CIR
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67226-1488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-706-2496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PETER JAMES SEBERGER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 316-260-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 0431068
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------