Provider Demographics
NPI:1740365717
Name:MID-AMERICA DIABETES ASSOCIATES, PA
Entity type:Organization
Organization Name:MID-AMERICA DIABETES ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUTHRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-644-0908
Mailing Address - Street 1:22015 W 101ST ST N
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:KS
Mailing Address - Zip Code:67108-9710
Mailing Address - Country:US
Mailing Address - Phone:316-644-0908
Mailing Address - Fax:
Practice Address - Street 1:8533 E 32ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-687-3100
Practice Address - Fax:316-687-0286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-15254207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100213320AMedicaid
KSCU0422OtherRAILROAD MEDICARE
KS004091Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER