Basic Information
| Provider Information | |||||||||
| NPI: | 1619260411 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST ANTHONY SHAWNEE HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST ANTHONY PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1102 W MACARTHUR ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058788110 | ||||||||
| FaxNumber: | 4058788101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 W MACARTHUR ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058788110 | ||||||||
| FaxNumber: | 4058788101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2011 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SKILLINGS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4058788110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.