1083616221 NPI number — OKMULGEE MEMORIAL HOSPITAL, INC

Table of content: (NPI 1083616221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083616221 NPI number — OKMULGEE MEMORIAL HOSPITAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKMULGEE MEMORIAL HOSPITAL, 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:
OKMULGEE 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:
1083616221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1038
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKMULGEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74447-1038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-756-4233
Provider Business Mailing Address Fax Number:
918-756-5968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 MORRIS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKMULGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74447-6429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-756-4233
Provider Business Practice Location Address Fax Number:
918-756-5968
Provider Enumeration Date:
06/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RIKER
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
DIRECTOR/IT
Authorized Official Telephone Number:
918-758-3135

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  2165 , 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: 100700360B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100260940A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 106260940A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000370057001 . This is a "BLUE CROSS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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