MEDICARE: WICHITA BONE & JOINT CENTER, PA

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	207X00000X	Orthopaedic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110921	OTHER	KS	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912021551
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICHITA BONE & JOINT CENTER, PA

Provider Business Mailing Address
First Line	:	PO BOX 780129
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67278-0129
Country	:	US
Telephone Number	:	316-945-9915
Fax Number	:	316-612-1910

Provider Business Practice Location Address
First Line	:	6634 W CENTRAL AVE
Second Line	:	SUITE 150
City	:	WICHITA
State	:	KS
Zip	:	67212-3315
Country	:	US
Telephone Number	:	316-945-9915
Fax Number	:	316-612-1910

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL P. ESTIVO
Credential	:	D.O.
Telephone Number	:	316-945-9915

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	06/19/2009

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