Provider Demographics
NPI:1467042754
Name:GLUTALITY PROVIDER GROUP OF KANSAS, PA.
Entity type:Organization
Organization Name:GLUTALITY PROVIDER GROUP OF KANSAS, PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-678-2026
Mailing Address - Street 1:401 FAIRWAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1800
Mailing Address - Country:US
Mailing Address - Phone:561-678-2026
Mailing Address - Fax:
Practice Address - Street 1:801 E DOUGLAS AVE FL 2
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3548
Practice Address - Country:US
Practice Address - Phone:561-678-2026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-21
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty