Basic Information
Provider Information | |||||||||
NPI: | 1437169489 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALDTON MUNICIPAL HOSPITAL (SNF) | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 918 S 8TH ST | ||||||||
Address2: |   | ||||||||
City: | HEALDTON | ||||||||
State: | OK | ||||||||
PostalCode: | 734382424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802290701 | ||||||||
FaxNumber: | 5802291454 | ||||||||
Practice Location | |||||||||
Address1: | 918 S 8TH ST | ||||||||
Address2: |   | ||||||||
City: | HEALDTON | ||||||||
State: | OK | ||||||||
PostalCode: | 734382424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802290701 | ||||||||
FaxNumber: | 5802291454 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 10/30/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | JEREMY | ||||||||
AuthorizedOfficialMiddleName: | ALLEN | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 5802290701 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2346 | OK | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 000373456001 | 01 | OK | OK BCBS 12-DIGIT # | OTHER | 100748330C | 05 | OK |   | MEDICAID |