Provider Demographics
NPI:1912969486
Name:HILLSIDE MEDICAL OFFICE LLC
Entity type:Organization
Organization Name:HILLSIDE MEDICAL OFFICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:316-685-1381
Mailing Address - Street 1:855 N HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4913
Mailing Address - Country:US
Mailing Address - Phone:316-685-1381
Mailing Address - Fax:
Practice Address - Street 1:855 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4913
Practice Address - Country:US
Practice Address - Phone:316-685-1381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS16399OtherBC/BS GROUP NUMBER
KS100087950AMedicaid
KS16399Medicare PIN
KS100087950AMedicaid