Basic Information
| Provider Information | |||||||||
| NPI: | 1205832003 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORDELL MEMORIAL HOSPITAL 0189 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CORDELL HOSPITAL AUTHORITY DBA CORDELL MEMORIAL HOSPITAL | ||||||||
| 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: | 1220 N GLENN L ENGLISH ST | ||||||||
| Address2: | |||||||||
| City: | CORDELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5808323339 | ||||||||
| FaxNumber: | 5808325076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUSS | ||||||||
| AuthorizedOfficialFirstName: | GEORGANNA | ||||||||
| AuthorizedOfficialMiddleName: | LEA | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5807744762 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORDELL MEMORIAL HOSPITAL 0189 | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2221 | OK | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 100819200B | 05 | OK | MEDICAID | 000370186001 | 01 | OK | BCBS OF OKLAHOMA | OTHER | 100819200A | 05 | OK | MEDICAID |