Provider Demographics
NPI:1073831954
Name:WESLEY MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:WESLEY MEDICAL CENTER, LLC
Other - Org Name:PEDIATRICS DIALYSIS SERVICE AT WESLEY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-962-2055
Mailing Address - Street 1:550 N HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4910
Mailing Address - Country:US
Mailing Address - Phone:316-962-2000
Mailing Address - Fax:316-688-7093
Practice Address - Street 1:550 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-962-2000
Practice Address - Fax:316-688-7093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
172307Medicare Oscar/Certification