Provider Demographics
NPI:1346286036
Name:AXTELL CLINIC, PA
Entity Type:Organization
Organization Name:AXTELL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:316-283-2800
Mailing Address - Street 1:700 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-9017
Mailing Address - Country:US
Mailing Address - Phone:316-283-2800
Mailing Address - Fax:316-283-3575
Practice Address - Street 1:700 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 210
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9017
Practice Address - Country:US
Practice Address - Phone:316-283-2800
Practice Address - Fax:316-283-3575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100003230AMedicaid
KS100003230AMedicaid
KS0562380001Medicare NSC
KS0562380002Medicare NSC