Basic Information
| Provider Information | |||||||||
| NPI: | 1831207836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUSAN B. ALLEN MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | SUSAN B. ALLEN DIALYSIS CENTER | ||||||||
| 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: | 3163212916 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163223300 | ||||||||
| FaxNumber: | 3163212916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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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 | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 633400 | 01 | KS | FIRST GUARD | OTHER | 001477 | 01 | KS | BLUE CROSS BLUE SHIELD | OTHER | 100009270H | 05 | KS | MEDICAID |