Provider Demographics
NPI:1679541627
Name:WESLEY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:WESLEY MEDICAL CENTER LLC
Other - Org Name:WESLEY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-962-2055
Mailing Address - Street 1:PO BOX 47490
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-7490
Mailing Address - Country:US
Mailing Address - Phone:316-962-3150
Mailing Address - Fax:316-962-7334
Practice Address - Street 1:850 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4914
Practice Address - Country:US
Practice Address - Phone:316-962-3070
Practice Address - Fax:316-962-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100327110EMedicaid
KS110458OtherBLUE CROSS BLUE SHIELD
KS110458OtherBLUE CROSS BLUE SHIELD