Provider Demographics
NPI:1326015447
Name:WICHITA DIAGNOSTIC PATHOLOGY LLC
Entity Type:Organization
Organization Name:WICHITA DIAGNOSTIC PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-962-2877
Mailing Address - Street 1:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0865
Mailing Address - Country:US
Mailing Address - Phone:316-962-2877
Mailing Address - Fax:
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:316-962-2877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty