Provider Demographics
NPI: | 1497126585 |
---|---|
Name: | MARIA MEDICAL SERVICES LLC |
Entity Type: | Organization |
Organization Name: | MARIA MEDICAL SERVICES LLC |
Other - Org Name: | MED-PED CLINIC OF WICHITA |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MANSOOR |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TAHIR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PA |
Authorized Official - Phone: | 316-440-2712 |
Mailing Address - Street 1: | 9415 E HARRY ST STE 202 |
Mailing Address - Street 2: | |
Mailing Address - City: | WICHITA |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67207-5076 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 316-691-0309 |
Mailing Address - Fax: | 316-691-0881 |
Practice Address - Street 1: | 9415 E HARRY ST STE 202 |
Practice Address - Street 2: | |
Practice Address - City: | WICHITA |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67207-5076 |
Practice Address - Country: | US |
Practice Address - Phone: | 316-691-0309 |
Practice Address - Fax: | 316-691-0881 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2015-10-14 |
Last Update Date: | 2015-10-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |