1700104718 NPI number — GOOD SHEPHERD HOSPICE OF MID-AMERICA INC

Table of content: (NPI 1700104718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700104718 NPI number — GOOD SHEPHERD HOSPICE OF MID-AMERICA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD SHEPHERD HOSPICE OF MID-AMERICA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700104718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4350 WILL ROGERS PKWY
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73108-1826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-943-0903
Provider Business Mailing Address Fax Number:
405-943-0950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1317 S FOUNTAIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLATHE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66061-7205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-322-3297
Provider Business Practice Location Address Fax Number:
913-948-7306
Provider Enumeration Date:
05/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DELESTER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-943-0903

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10404900B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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