Provider Demographics
NPI:1952670077
Name:PRAIRIE GYNECOLOGY PA
Entity Type:Organization
Organization Name:PRAIRIE GYNECOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN, BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-305-2330
Mailing Address - Street 1:13716 E MAINSGATE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67228-8049
Mailing Address - Country:US
Mailing Address - Phone:316-305-2093
Mailing Address - Fax:
Practice Address - Street 1:12115 E 21ST ST N
Practice Address - Street 2:STE 107
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3567
Practice Address - Country:US
Practice Address - Phone:316-305-2093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0433994207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty