Basic Information
| Provider Information | |||||||||
| NPI: | 1164859260 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRADY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FIVE OAKS FAMILY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 W IOWA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | 4057792346 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W IOWA AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052242100 | ||||||||
| FaxNumber: | 4057792346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2013 | ||||||||
| LastUpdateDate: | 09/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | SPELLMAN | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | KEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4057792150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QR1300X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 100700820 K | 05 | OK | MEDICAID |