Provider Demographics
NPI:1124594957
Name:SUSAN B. ALLEN MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SUSAN B. ALLEN MEMORIAL HOSPITAL
Other - Org Name:SBA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-322-4558
Mailing Address - Street 1:720 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2112
Mailing Address - Country:US
Mailing Address - Phone:316-321-3300
Mailing Address - Fax:316-321-4810
Practice Address - Street 1:700 W CENTRAL AVE STE 103
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2187
Practice Address - Country:US
Practice Address - Phone:316-321-8751
Practice Address - Fax:316-321-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty