Basic Information
Provider Information | |||||||||
NPI: | 1073841623 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRISTOW MEDICAL CENTER OPERATING COMPANY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRISTOW MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 W 7TH AVE | ||||||||
Address2: | SUITE 6 | ||||||||
City: | BRISTOW | ||||||||
State: | OK | ||||||||
PostalCode: | 740102302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183672215 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 700 W 7TH AVE | ||||||||
Address2: | SUITE 6 | ||||||||
City: | BRISTOW | ||||||||
State: | OK | ||||||||
PostalCode: | 740102302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183672215 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2009 | ||||||||
LastUpdateDate: | 11/19/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EARNHARDT | ||||||||
AuthorizedOfficialFirstName: | STAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTH OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 9183672215 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   |   | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.