Provider Demographics
NPI:1912021551
Name:WICHITA BONE & JOINT CENTER, PA
Entity Type:Organization
Organization Name:WICHITA BONE & JOINT CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:ESTIVO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:316-945-9915
Mailing Address - Street 1:PO BOX 780129
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67278-0129
Mailing Address - Country:US
Mailing Address - Phone:316-945-9915
Mailing Address - Fax:316-612-1910
Practice Address - Street 1:6634 W CENTRAL AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-3315
Practice Address - Country:US
Practice Address - Phone:316-945-9915
Practice Address - Fax:316-612-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110921OtherBLUE CROSS BLUE SHIELD
KS200003070AMedicaid
KS1102110001Medicare NSC
KS110921Medicare ID - Type Unspecified