Provider Demographics
NPI:1497574693
Name:GHANEM, ROY
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:GHANEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 N ROCK RD APT 605
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1227
Mailing Address - Country:US
Mailing Address - Phone:316-236-2342
Mailing Address - Fax:
Practice Address - Street 1:550 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4976
Practice Address - Country:US
Practice Address - Phone:316-962-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-12070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics