Provider Demographics
NPI:1013441930
Name:FREESTATE HEALTH PLLC
Entity Type:Organization
Organization Name:FREESTATE HEALTH PLLC
Other - Org Name:FREESTATE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YAGHMAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH&TM
Authorized Official - Phone:888-505-1776
Mailing Address - Street 1:4723 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1012
Mailing Address - Country:US
Mailing Address - Phone:888-505-1776
Mailing Address - Fax:888-505-1776
Practice Address - Street 1:4723 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1012
Practice Address - Country:US
Practice Address - Phone:888-505-1776
Practice Address - Fax:888-505-1776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33447207R00000X, 208000000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty