Basic Information
Provider Information | |||||||||
NPI: | 1356308746 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLAREMORE REGIONAL HOSPITAL LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLAREMORE REGIONAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 848457 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752848457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183426705 | ||||||||
FaxNumber: | 9183423330 | ||||||||
Practice Location | |||||||||
Address1: | 1202 N MUSKOGEE PL | ||||||||
Address2: |   | ||||||||
City: | CLAREMORE | ||||||||
State: | OK | ||||||||
PostalCode: | 740173058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183426705 | ||||||||
FaxNumber: | 9183423330 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2006 | ||||||||
LastUpdateDate: | 11/05/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
AuthorizedOfficialFirstName: | LAURIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, BUSINESS OFFICE SERVICES | ||||||||
AuthorizedOfficialTelephone: | 6154657466 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CLAREMORE REGIONAL HOSPITAL LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2192 | OK | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.