1265602056 NPI number — CRAIG COUNTY HOSPITAL AUTHORITY

Table of content: (NPI 1265602056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265602056 NPI number — CRAIG COUNTY HOSPITAL AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG COUNTY HOSPITAL AUTHORITY
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:
GRAND LAKE MEDICAL PARK - MONKEY ISLAND
Provider Other Organization Name Type Code:
3
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:
1265602056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 326
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINITA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74301-0326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-256-7551
Provider Business Mailing Address Fax Number:
918-256-3703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26300 S HIGHWAY 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AFTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74331-6282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-257-8585
Provider Business Practice Location Address Fax Number:
918-257-8560
Provider Enumeration Date:
03/07/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRUM
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
918-256-7551

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  2182 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 282NR1301X , with the licence number: 2182 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100261400K , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".