Basic Information
| Provider Information | |||||||||
| NPI: | 1407890692 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SKILLED NURSING FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 W 15TH STREET | ||||||||
| Address2: | PO BOX 1340 | ||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679051340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206241651 | ||||||||
| FaxNumber: | 6206292472 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679012455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206241651 | ||||||||
| FaxNumber: | 6206292472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 12/12/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERMANN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6206296400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 175163 | KS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 118 | 01 | KS | BCBS | OTHER |