Provider Demographics
NPI:1417983032
Name:MELLION, B THEO (PHD, MD)
Entity Type:Individual
Prefix:
First Name:B
Middle Name:THEO
Last Name:MELLION
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 N WEBB RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8175
Mailing Address - Country:US
Mailing Address - Phone:316-609-2600
Mailing Address - Fax:206-609-2800
Practice Address - Street 1:3223 N WEBB RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8175
Practice Address - Country:US
Practice Address - Phone:316-609-2600
Practice Address - Fax:206-609-2800
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430952207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200270470BMedicaid
KSF28646Medicare UPIN
KS200270470BMedicaid