1023064300 NPI number — BROOKHAVEN HOSPITAL, LLC

Table of content: (NPI 1023064300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023064300 NPI number — BROOKHAVEN HOSPITAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKHAVEN HOSPITAL, LLC
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:
1023064300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 S GARNETT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74128-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-438-4257
Provider Business Mailing Address Fax Number:
918-438-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 S GARNETT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-438-4257
Provider Business Practice Location Address Fax Number:
918-438-0083
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
NOEL
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
918-438-4257

Provider Taxonomy Codes

  • Taxonomy code: 273Y00000X , with the licence number:  2313 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 2313 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100701410A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100701410C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0157430 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026694200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023064300 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100299900B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100701410B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160837125 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00401269 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0901223 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q029771 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023064300 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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