Basic Information
| Provider Information | |||||||||
| NPI: | 1568705267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE SERVICES - SAINT JOHN LEAVENWORTH, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAINT JOHN HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092354362 | ||||||||
| FaxNumber: | 9092354418 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LEAVENWORTH | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660485043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092354362 | ||||||||
| FaxNumber: | 9092354418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2013 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEON | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF OPERATIONS II | ||||||||
| AuthorizedOfficialTelephone: | 9092354362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | KS | Y | Hospitals | General Acute Care Hospital |
No ID Information.