Basic Information
| Provider Information | |||||||||
| NPI: | 1033113097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ANTHONY SHAWNEE HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SSM HEALTH ST. ANTHONY HOSPITAL - SHAWNEE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1102 W MACARTHUR ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052732270 | ||||||||
| FaxNumber: | 4058788101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 S GORDON COOPER DR | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052732270 | ||||||||
| FaxNumber: | 4058788101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKILLINGS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT-CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4058788110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. ANTHONY SHAWNEE HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 2162 | OK | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 100740840B | 05 | OK | MEDICAID | 000370149001 | 01 | OK | BCBS | OTHER |