Provider Demographics
NPI:1285685008
Name:MID-KANSAS DERMATOLOGY CLINIC, PA
Entity Type:Organization
Organization Name:MID-KANSAS DERMATOLOGY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-612-1833
Mailing Address - Street 1:1861 N ROCK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-4200
Mailing Address - Country:US
Mailing Address - Phone:316-612-1833
Mailing Address - Fax:316-612-2420
Practice Address - Street 1:1861 N ROCK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-4200
Practice Address - Country:US
Practice Address - Phone:316-612-1833
Practice Address - Fax:316-612-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-20338207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110898Medicare PIN