Provider Demographics
NPI:1033628243
Name:KANSAS SPINE & SPECIALTY HOSPITAL, L.L.C.
Entity Type:Organization
Organization Name:KANSAS SPINE & SPECIALTY HOSPITAL, L.L.C.
Other - Org Name:KANSAS SPINE & SPECIALTY PAIN CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5935
Mailing Address - Street 1:3333 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8123
Mailing Address - Country:US
Mailing Address - Phone:316-462-5338
Mailing Address - Fax:316-462-5345
Practice Address - Street 1:3223 N WEBB RD STE 3
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8176
Practice Address - Country:US
Practice Address - Phone:316-462-5000
Practice Address - Fax:316-462-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200257840AMedicaid