Basic Information
| Provider Information | |||||||||
| NPI: | 1427295872 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEVELAND AREA HOSPITAL HOLDINGS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CLEVELAND AREA HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1401 W PAWNEE ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740203033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183582501 | ||||||||
| FaxNumber: | 9183589274 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 WEST PAWNEE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183582501 | ||||||||
| FaxNumber: | 9183589274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENTON | ||||||||
| AuthorizedOfficialFirstName: | EDRED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9183585647 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 200234090A | 05 | OK | MEDICAID | 200234090B | 05 | OK | MEDICAID |