Provider Demographics
NPI:1659327245
Name:COSMETIC & RECONSTRUCTIVE SURGERY CENTER, PA
Entity Type:Organization
Organization Name:COSMETIC & RECONSTRUCTIVE SURGERY CENTER, PA
Other - Org Name:COSMETIC & RECONSTRUCTIVE SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-681-2227
Mailing Address - Street 1:1700 N WATERFRONT PKWY
Mailing Address - Street 2:BUILDING 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-6614
Mailing Address - Country:US
Mailing Address - Phone:316-681-2227
Mailing Address - Fax:316-684-5250
Practice Address - Street 1:1700 N WATERFRONT PKWY
Practice Address - Street 2:BUILDING 200
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-6614
Practice Address - Country:US
Practice Address - Phone:316-681-2227
Practice Address - Fax:316-684-5250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0429556261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS112227Medicare Oscar/Certification
KS112227Medicare PIN