Provider Demographics
NPI:1760564199
Name:ELDORADO OBSTETRICS AND GYNECOLOGY PA
Entity Type:Organization
Organization Name:ELDORADO OBSTETRICS AND GYNECOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OBGYN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:ALETHA
Authorized Official - Last Name:RUSSELL MCKESEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-320-0501
Mailing Address - Street 1:700 WEST CENTRAL
Mailing Address - Street 2:SUITE 412
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042
Mailing Address - Country:US
Mailing Address - Phone:316-320-0501
Mailing Address - Fax:316-321-0503
Practice Address - Street 1:700 WEST CENTRAL
Practice Address - Street 2:SUITE 412
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042
Practice Address - Country:US
Practice Address - Phone:316-320-0501
Practice Address - Fax:316-321-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430298207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100642490AMedicaid
KS103157OtherBCBS OF KS
KS453460OtherFIBTGUARD
KS453460OtherFIBTGUARD
KS100642490AMedicaid