Basic Information
| Provider Information | |||||||||
| NPI: | 1588156574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUSAN B. ALLEN MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SBA URGENT CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163213300 | ||||||||
| FaxNumber: | 3163214810 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 W CENTRAL AVE STE A | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670423283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164525860 | ||||||||
| FaxNumber: | 3164525844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3163224558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.