Basic Information
| Provider Information | |||||||||
| NPI: | 1265546048 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FREEMAN-OAK HILL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FREEMAN HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1102 W 32ND ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173471111 | ||||||||
| FaxNumber: | 4173479311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 W 32ND ST | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173471111 | ||||||||
| FaxNumber: | 4173479311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRADDY | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4173476678 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100693570A | 05 | OK | MEDICAID | 32067 | 01 | MO | BLUE CHOICE | OTHER | 010565208 | 05 | MO | MEDICAID | 540565207 | 05 | MO | MEDICAID | 100711500O | 05 | OK | MEDICAID | 80108 | 01 | KS | BLUE CROSS KANSAS | OTHER | 100099600A | 05 | KS | MEDICAID |