Basic Information
| Provider Information | |||||||||
| NPI: | 1295232478 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AHS HENRYETTA HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UTICA PARK CLINIC PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENRYETTA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744373893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186501180 | ||||||||
| FaxNumber: | 9186501294 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 W MAIN ST STE A | ||||||||
| Address2: | |||||||||
| City: | HENRYETTA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186501180 | ||||||||
| FaxNumber: | 9186501294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2018 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AHS HILLCREST HEALTHCARE SYSTEM, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.