Basic Information
| Provider Information | |||||||||
| NPI: | 1063767259 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODWARD HEALTH SYSTEM LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLIANCEHEALTH WOODWARD CLINICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738012448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802565511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738013045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802548692 | ||||||||
| FaxNumber: | 5802548687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2012 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6292153953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WOODWARD HEALTH SYSTEM LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 20019120J | 05 | OK | MEDICAID |