Basic Information
| Provider Information | |||||||||
| NPI: | 1376757401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MCCURTAIN MEMORIAL HOSPITAL RADIOLOGY PHY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E LINCOLN ROAD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083100 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 E LINCOLN ROAD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083100 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITMORE | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5802083104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100700920B | 05 | OK | MEDICAID |