Basic Information
| Provider Information | |||||||||
| NPI: | 1104375237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STILLWATER MEDICAL CENTER AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STILLWATER MEDICAL - BLACKWELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720006 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055335300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 710 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | BLACKWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746313700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2016 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOZIKUSKI | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5803632311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.