1700977808 NPI number — DHHS US PUBLIC HEALTH SERVICE INDIAN HEALTH SERVICE

Table of content: (NPI 1700977808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700977808 NPI number — DHHS US PUBLIC HEALTH SERVICE INDIAN HEALTH SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DHHS US PUBLIC HEALTH SERVICE INDIAN HEALTH SERVICE
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:
1700977808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 GRANDVIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWHUSKA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-287-4491
Provider Business Mailing Address Fax Number:
918-287-2347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101S MOORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAREMORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74017-5047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-287-4491
Provider Business Practice Location Address Fax Number:
918-287-2347
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDEN
Authorized Official First Name:
AMY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
918-287-4491

Provider Taxonomy Codes

  • Taxonomy code: 261QP0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100689200D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100700620N . This is a "MEDICAID CAP" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100231960F . This is a "MEDICAID RX" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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