Basic Information
| Provider Information | |||||||||
| NPI: | 1104968916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUSKOGEE REGIONAL MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTAR HEALTH SYSTEM MAIN CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 CONTINENTAL PL | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370271041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158449800 | ||||||||
| FaxNumber: | 6158449883 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 ROCKEFELLER DR | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744015075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186825501 | ||||||||
| FaxNumber: | 9186842552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6158449800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2177 | OK | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100700630A | 05 | OK | MEDICAID | 000370025001 | 01 | OK | BLUE CROSS PROVIDER ID | OTHER |