Basic Information
| Provider Information | |||||||||
| NPI: | 1427061852 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AHS CUSHING HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HILLCREST REGIONAL HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | CUSHING | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740234201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182252915 | ||||||||
| FaxNumber: | 9182252517 | ||||||||
| Practice Location | |||||||||
| Address1: | 1223 E CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | CUSHING | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740234201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182252915 | ||||||||
| FaxNumber: | 9182252517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUBOIS | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9182258150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7236 | OK | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 200044190B | 05 | OK | MEDICAID |