1568643005 NPI number — SGOH ACQUISITION INC

Table of content: (NPI 1568643005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568643005 NPI number — SGOH ACQUISITION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SGOH ACQUISITION 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:
OZARKS COMMUNITY HOSPITAL OF GRAVETTE
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:
1568643005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 JACKSON ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAVETTE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72736-9121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-787-5291
Provider Business Mailing Address Fax Number:
417-832-9041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 JACKSON ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAVETTE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72736-9121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-837-4000
Provider Business Practice Location Address Fax Number:
417-875-4791
Provider Enumeration Date:
11/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
GREGORY
Authorized Official Title or Position:
ADMINISTRATOR/CEO
Authorized Official Telephone Number:
417-837-4090

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  AR4517 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: AR4517 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC0050X , with the licence number: AR4517 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NC0060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1568643005 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200200390A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168370105 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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