Provider Demographics
NPI:1356488837
Name:RIDGEWOOD SURGERY AND ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:RIDGEWOOD SURGERY AND ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELANOR
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-314-9193
Mailing Address - Street 1:4013 NORTH RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-8822
Mailing Address - Country:US
Mailing Address - Phone:913-314-9193
Mailing Address - Fax:
Practice Address - Street 1:4013 NORTH RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-8822
Practice Address - Country:US
Practice Address - Phone:913-314-9193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00428555OtherRAILROAD MEDICARE
KS112228OtherBLUE CROSS BLUE SHIELD KS
KS112228Medicare PIN