1295232478 NPI number — AHS HENRYETTA HOSPITAL LLC

Table of content: (NPI 1295232478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295232478 NPI number — AHS HENRYETTA HOSPITAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AHS HENRYETTA 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:
UTICA PARK CLINIC PRIMARY CARE
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:
1295232478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2405 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENRYETTA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74437-3893
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-650-1180
Provider Business Mailing Address Fax Number:
918-650-1294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2405 W MAIN ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENRYETTA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-650-1180
Provider Business Practice Location Address Fax Number:
918-650-1294
Provider Enumeration Date:
04/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
PETROVICH
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
EVP
Authorized Official Telephone Number:
615-296-3000

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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