Basic Information
| Provider Information | |||||||||
| NPI: | 1407828908 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STILLWATER MEDICAL CENTER AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STILLWATER MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1323 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053721480 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1323 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053721480 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOELLER | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4057425701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 2272 | OK | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.