1235170754 NPI number — JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY

Table of content: (NPI 1235170754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235170754 NPI number — JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
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:
6
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:
1235170754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1204 E TAMARACK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTUS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73521-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-379-6900
Provider Business Mailing Address Fax Number:
580-379-6909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 E TAMARACK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTUS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73521-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-379-6900
Provider Business Practice Location Address Fax Number:
580-379-6909
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARTGRAVES
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
580-379-5000

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  4040 , 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)





Copyright © 2007-2025 www.npivalidator.com