Provider Demographics
NPI:1154535060
Name:MIDWEST PSYCHIATRIC PA
Entity type:Organization
Organization Name:MIDWEST PSYCHIATRIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MAGDALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTILO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-568-7667
Mailing Address - Street 1:5300 W 94TH TER STE 200
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207-2536
Mailing Address - Country:US
Mailing Address - Phone:913-381-8555
Mailing Address - Fax:913-677-2112
Practice Address - Street 1:5300 W 94TH TER STE 200
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207-2536
Practice Address - Country:US
Practice Address - Phone:913-381-8555
Practice Address - Fax:913-677-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04270072084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203768908-AMedicaid
KS100384540BMedicaid
MO203768908-AMedicaid
G68925Medicare UPIN