Provider Demographics
NPI:1396238010
Name:WICHITA NEPHROLOGY GROUP, PA
Entity type:Organization
Organization Name:WICHITA NEPHROLOGY GROUP, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WISSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SALIBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-263-5891
Mailing Address - Street 1:2122 N GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3023
Mailing Address - Country:US
Mailing Address - Phone:316-263-5891
Mailing Address - Fax:316-263-3083
Practice Address - Street 1:2122 N GARNETT ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3023
Practice Address - Country:US
Practice Address - Phone:316-636-1234
Practice Address - Fax:316-636-2630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WICHITA NEPHROLOGY GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-07
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-35548261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical