Basic Information
| Provider Information | |||||||||
| NPI: | 1306899620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOODWARD HEALTH SYSTEM LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 555 | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802565511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 738012448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802565511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8778929813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2252 | OK | N | Ambulatory Health Care Facilities | Clinic/Center | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 20001920C | 05 | OK | MEDICAID |