Provider Demographics
NPI:1497857551
Name:GOOD SHEPHERD HOSPICE OF MID-AMERICA INC
Entity Type:Organization
Organization Name:GOOD SHEPHERD HOSPICE OF MID-AMERICA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:DELESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-943-0903
Mailing Address - Street 1:123 W KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64050-3732
Mailing Address - Country:US
Mailing Address - Phone:816-822-2292
Mailing Address - Fax:816-822-2298
Practice Address - Street 1:123 W KANSAS AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-3713
Practice Address - Country:US
Practice Address - Phone:816-822-2292
Practice Address - Fax:816-822-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1243H0251G00000X
251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100404900AOtherMEDICAID
KS10404900BMedicaid
MO826099202Medicaid
KS10404900BMedicaid