Provider Demographics
NPI:1063453959
Name:HILLSIDE MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:HILLSIDE MEDICAL GROUP, P.A.
Other - Org Name:OSTEOPATHIC CLINIC, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-221-0110
Mailing Address - Street 1:1700 E 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-3220
Mailing Address - Country:US
Mailing Address - Phone:620-221-0110
Mailing Address - Fax:620-221-0623
Practice Address - Street 1:1700 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-3220
Practice Address - Country:US
Practice Address - Phone:620-221-0110
Practice Address - Fax:620-221-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110252OtherBC/BS
KS110252Medicare ID - Type Unspecified