MEDICARE: DR. JOHN R WHITEHEAD D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	05-20530	KS
2	207Q00000X	Family Medicine Physician	05-20530	KS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00615209	OTHER	KS	RR MEDICARE (PALMETTO)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265431860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN R WHITEHEAD D.O.

Provider Business Mailing Address
First Line	:	2610 N WOODLAWN BLVD
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-2729
Country	:	US
Telephone Number	:	316-858-2610
Fax Number	:	316-858-2793

Provider Business Practice Location Address
First Line	:	2610 N WOODLAWN BLVD
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-2729
Country	:	US
Telephone Number	:	316-858-2610
Fax Number	:	316-858-2793

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	12/17/2010

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Directions to “ DR. JOHN R WHITEHEAD D.O.” Practice Location

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