Provider Demographics
NPI:1922520832
Name:SUSAN B. ALLEN MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SUSAN B. ALLEN MEMORIAL HOSPITAL
Other - Org Name:SBA MEDICAL GROUP - AUGUSTA
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 1:401 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010-1309
Practice Address - Country:US
Practice Address - Phone:316-558-8668
Practice Address - Fax:316-558-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty