Basic Information
| Provider Information | |||||||||
| NPI: | 1548468648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN B. ALLEN MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | FLINTHILLS ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163223300 | ||||||||
| FaxNumber: | 3163222916 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W CENTRAL AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163219813 | ||||||||
| FaxNumber: | 3163229806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | KIRKBRIDE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3163224557 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | 04-31540 | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XS0117X | 04-31540 | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 04-31540 | KS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200373470C | 05 | KS | MEDICAID | 170017 | 01 | KS | MEDICARE PART A | OTHER | 100009270G | 01 | KS | KMAP | OTHER | 111282 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER |