Basic Information
| Provider Information | |||||||||
| NPI: | 1043339559 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MCCURTAIN MEMORIAL HOSPITAL SWING BED | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802867623 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802867623 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITMORE | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5802083104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2202 | OK | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.