Provider Demographics
NPI:1184281131
Name:KANSAS PEDIATRIC NEUROLOGY CENTER LLC
Entity type:Organization
Organization Name:KANSAS PEDIATRIC NEUROLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSEM
Authorized Official - Middle Name:
Authorized Official - Last Name:EL-NABBOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-253-8090
Mailing Address - Street 1:10111 E 21ST ST N STE 405
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3508
Mailing Address - Country:US
Mailing Address - Phone:316-796-5610
Mailing Address - Fax:316-796-5611
Practice Address - Street 1:10111 E 21ST ST N STE 405
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3508
Practice Address - Country:US
Practice Address - Phone:316-796-5610
Practice Address - Fax:316-796-5611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSPENDINGMedicaid