Basic Information
Provider Information | |||||||||
NPI: | 1316945272 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOGAN HOSPITAL AND MEDICAL CENTER AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTER FOR INTERNAL MEDICINE AND PEDICATRICS - ACADEMY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1017 | ||||||||
Address2: |   | ||||||||
City: | GUTHRIE | ||||||||
State: | OK | ||||||||
PostalCode: | 730441017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052829449 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 205 S ACADEMY RD | ||||||||
Address2: |   | ||||||||
City: | GUTHRIE | ||||||||
State: | OK | ||||||||
PostalCode: | 730448727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052829449 | ||||||||
FaxNumber: | 4052829403 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 11/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROWLEY | ||||||||
AuthorizedOfficialFirstName: | STEVE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4052604191 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2267 | OK | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | CJ5177 | 01 |   | MEDICARE RAILROAD | OTHER |