Basic Information
| Provider Information | |||||||||
| NPI: | 1083757926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUSKOGEE REGIONAL MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MUSKOGEE REGIONAL MEDICAL CENTER REHABILITATION UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 CORPORATE CENTRE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370672659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157764300 | ||||||||
| FaxNumber: | 6157643030 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 ROCKEFELLER DR | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744015075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186825501 | ||||||||
| FaxNumber: | 9186842552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 12/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | SLIPKOVICH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6157643000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUSKOGEE MEDICAL CENTER, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 2177 | OK | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 100700630G | 05 | OK | MEDICAID |