Provider Demographics
NPI:1124111687
Name:MISSION MEDICAL GROUP OF KANSAS, PA
Entity type:Organization
Organization Name:MISSION MEDICAL GROUP OF KANSAS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GALLUP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-662-4560
Mailing Address - Street 1:45 M AIN STREET
Mailing Address - Street 2:SUITE 408
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:866-662-4560
Mailing Address - Fax:877-279-9425
Practice Address - Street 1:2942B SW WANAMAKER DRIVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66614
Practice Address - Country:US
Practice Address - Phone:866-662-4560
Practice Address - Fax:877-279-9425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty