MEDICARE: DR. CHARLES A GAYNOR LP

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	103TC0700X	Clinical Psychologist	0405	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	022101	OTHER	KS	BLUE CROSS
2	4205	OTHER	KS	PREFERRED HEALTH SYSTEMS
3	2144774	OTHER	KS	CIGNA
4	PV115577	OTHER	KS	AMERICAN PSYCH SYSTEMS

General Provider Information

NPI Number	:	1952349193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES A GAYNOR LP

Provider Business Mailing Address
First Line	:	635 N MAIN ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67203-3602
Country	:	US
Telephone Number	:	316-660-7600
Fax Number	:	316-383-7925

Provider Business Practice Location Address
First Line	:	1919 N AMIDON AVE
Second Line	:	STE. 130
City	:	WICHITA
State	:	KS
Zip	:	67203-2117
Country	:	US
Telephone Number	:	316-660-7675
Fax Number	:	316-832-1571

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. CHARLES A GAYNOR LP” Practice Location

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