Basic Information
| Provider Information | |||||||||
| NPI: | 1841395431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGIVERN | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.P.T | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLIS | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2200 SW GAGE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666222003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853503111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 SW GAGE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666222003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853503111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 1102564 | KS | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DD6064 | 01 | KS | RR MEDICARE | OTHER | 140938 | 01 | KS | BCBS | OTHER |