Basic Information
| Provider Information | |||||||||
| NPI: | 1215084439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISHNA | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | BERENBOM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERENBOM | ||||||||
| OtherFirstName: | ANNE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 219241 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641219241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138295511 | ||||||||
| FaxNumber: | 9138295571 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661607200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135881227 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 06/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 240818 | NY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 04-34367 | KS | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200678210A | 05 | KS | MEDICAID | P00860901 | 01 | KS | RR MEDICARE | OTHER |