Basic Information
Provider Information | |||||||||
NPI: | 1205881125 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOLARA HOSPITAL SHAWNEE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORNERSTONE SPECIALTY HOSPITALS SHAWNEE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2200 ROSS AVE | ||||||||
Address2: | STE 5400 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752017918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4696216700 | ||||||||
FaxNumber: | 4696216678 | ||||||||
Practice Location | |||||||||
Address1: | 1900 GORDON COOPER DR | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | SHAWNEE | ||||||||
State: | OK | ||||||||
PostalCode: | 748018603 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053955800 | ||||||||
FaxNumber: | 4053955802 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 10/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHULTZ | ||||||||
AuthorizedOfficialFirstName: | KURT | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 4696216700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 2363 | OK | Y |   | Hospitals | Long Term Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 200080160A | 05 | OK |   | MEDICAID |