1629020177 NPI number — MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC.

Table of content: (NPI 1629020177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629020177 NPI number — MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, 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:
MCCURTAIN 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:
1629020177
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 E LINCOLN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDABEL
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74745-7300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-208-3100
Provider Business Mailing Address Fax Number:
580-208-3199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 E LINCOLN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDABEL
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74745-7300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-208-3100
Provider Business Practice Location Address Fax Number:
580-208-3199
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITMORE
Authorized Official First Name:
RAY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
580-208-3104

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 7071 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 273R00000X , with the licence number: 2202 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 275N00000X , with the licence number: 2202 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X , with the licence number: 2202 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 100700920H , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100700920A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100700920B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9R049 . This is a "BCBS AR" identifier . This identifiers is of the category "OTHER".
  • Identifier: CD0496 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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