Basic Information
| Provider Information | |||||||||
| NPI: | 1407015530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL OKLAHOMA FAMILY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748491415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | KONAWA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748491415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809253286 | ||||||||
| FaxNumber: | 5809252362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANSON | ||||||||
| AuthorizedOfficialFirstName: | CASEY | ||||||||
| AuthorizedOfficialMiddleName: | HAROLD | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5809253286 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 100737160P | 05 | OK | MEDICAID |