Provider Demographics
NPI:1205164282
Name:BERNARD T. POOLE, MD, PA
Entity type:Organization
Organization Name:BERNARD T. POOLE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-264-2806
Mailing Address - Street 1:818 N EMPORIA ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3729
Mailing Address - Country:US
Mailing Address - Phone:316-264-2806
Mailing Address - Fax:316-264-4716
Practice Address - Street 1:818 N EMPORIA ST
Practice Address - Street 2:SUITE 107
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3729
Practice Address - Country:US
Practice Address - Phone:316-264-2806
Practice Address - Fax:316-264-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100081750AMedicaid
KSB68266Medicare UPIN