Basic Information
| Provider Information | |||||||||
| NPI: | 1700994977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUSAN B. ALLEN MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUSAN B. ALLEN MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W. CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163213300 | ||||||||
| FaxNumber: | 3163212916 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 W. CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163213300 | ||||||||
| FaxNumber: | 3163212916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 3163224558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 2-08568 | KS | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | N | Suppliers | Pharmacy | Institutional Pharmacy | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 2160905 | 01 | PK | OTHER |