Provider Demographics
NPI:1326399205
Name:CONCIERGE MEDICINE OF WICHITA LLC
Entity Type:Organization
Organization Name:CONCIERGE MEDICINE OF WICHITA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GADALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-462-1070
Mailing Address - Street 1:9449 E 21ST ST N
Mailing Address - Street 2:STE. 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2969
Mailing Address - Country:US
Mailing Address - Phone:316-462-1070
Mailing Address - Fax:316-462-1078
Practice Address - Street 1:9449 E 21ST ST N
Practice Address - Street 2:STE. 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2969
Practice Address - Country:US
Practice Address - Phone:316-462-1070
Practice Address - Fax:316-462-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-29832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPENDINGMedicaid
KSPENDINGMedicare PIN