Provider Demographics
NPI:1497829261
Name:OHAEBOSIM MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:OHAEBOSIM MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINUS
Authorized Official - Middle Name:C
Authorized Official - Last Name:OHAEBOSIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:316-681-1901
Mailing Address - Street 1:2810 E 21ST STREET
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2252
Mailing Address - Country:US
Mailing Address - Phone:316-681-1901
Mailing Address - Fax:316-618-7362
Practice Address - Street 1:2810 E 21ST STREET
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2252
Practice Address - Country:US
Practice Address - Phone:316-681-1901
Practice Address - Fax:316-618-7362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0516911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
614790OtherFIRST GUARD
KS693OtherPHS
KS49202OtherBLUE SHIELD
4083832OtherAETNA
KS100098690AMedicaid
4083832OtherAETNA
KS049202Medicare ID - Type Unspecified