Basic Information
| Provider Information | |||||||||
| NPI: | 1396923280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICKASAW NATION DIVISION OF HEALTH CHICKASAW NATION MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHICKASAW NATION MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1925 WARRIOR WAY | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER BLVD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MEEKS | ||||||||
| AuthorizedOfficialFirstName: | KIRBI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGEMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5804214570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | EMS300 | OK | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 100747670E | 05 | OK | MEDICAID | EMS300 | 01 | OK | STATE LICENSE | OTHER |