1679550115 NPI number — COUNTY OF TILLMAN - CITY OF FREDERICK HOSPITAL AUTHORITY

Table of content: (NPI 1679550115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679550115 NPI number — COUNTY OF TILLMAN - CITY OF FREDERICK HOSPITAL AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF TILLMAN - CITY OF FREDERICK 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:
MEMORIAL HOSPITAL
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:
1679550115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
319 E JOSEPHINE AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73542-2220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-335-6600
Provider Business Mailing Address Fax Number:
580-335-5044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 E JOSEPHINE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73542-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-335-6600
Provider Business Practice Location Address Fax Number:
580-335-5044
Provider Enumeration Date:
12/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ADE
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
BOARD CHAIRMAN
Authorized Official Telephone Number:
580-335-6642

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  7103 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100776110B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10076110B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".