Basic Information
Provider Information | |||||||||
NPI: | 1134532344 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORDELL MEMORIAL HOSPITAL 0189 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORDELL MEMORIAL HOSPITAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1220 N GLENN L ENGLISH ST | ||||||||
Address2: |   | ||||||||
City: | CORDELL | ||||||||
State: | OK | ||||||||
PostalCode: | 736322010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5808323339 | ||||||||
FaxNumber: | 5808325076 | ||||||||
Practice Location | |||||||||
Address1: | 1109 N GLENN L ENGLISH ST | ||||||||
Address2: |   | ||||||||
City: | CORDELL | ||||||||
State: | OK | ||||||||
PostalCode: | 736322007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5808323339 | ||||||||
FaxNumber: | 5808325076 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2014 | ||||||||
LastUpdateDate: | 02/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUSS | ||||||||
AuthorizedOfficialFirstName: | GEORGANNA | ||||||||
AuthorizedOfficialMiddleName: | LEA | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5807744762 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2221 | OK | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.