Provider Demographics
NPI:1073623724
Name:STAFFORD COUNTY HOSPITAL
Entity Type:Organization
Organization Name:STAFFORD COUNTY HOSPITAL
Other - Org Name:STAFFORD COUNTY HOSPITAL HOME HEALTH AGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-234-5221
Mailing Address - Street 1:502 SOUTH BUCKEYE STREET
Mailing Address - Street 2:PO BOX 190
Mailing Address - City:STAFFORD
Mailing Address - State:KS
Mailing Address - Zip Code:67578-0190
Mailing Address - Country:US
Mailing Address - Phone:620-234-5221
Mailing Address - Fax:620-234-5792
Practice Address - Street 1:502 S BUCKEYE ST
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:KS
Practice Address - Zip Code:67578-2035
Practice Address - Country:US
Practice Address - Phone:620-234-5221
Practice Address - Fax:620-234-5792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA093002251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100099380EMedicaid
KS001176OtherBCBS
KS100099380CMedicaid
KS100099380CMedicaid