Basic Information
| Provider Information | |||||||||
| NPI: | 1326098914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOSEPH MEMORIAL HOSPITAL, INC. | ||||||||
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| OtherOrganizationName: | ST JOSEPH FAMILY MEDICINE-LARNED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 970 | ||||||||
| Address2: | |||||||||
| City: | GREAT BEND | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675300970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207866475 | ||||||||
| FaxNumber: | 6207866155 | ||||||||
| Practice Location | |||||||||
| Address1: | 713 W 11TH ST | ||||||||
| Address2: | |||||||||
| City: | LARNED | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675502055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202856958 | ||||||||
| FaxNumber: | 6202852173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | LIND | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6207866101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100112110D | 05 | KS | MEDICAID |