Basic Information
| Provider Information | |||||||||
| NPI: | 1447363783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACKWELL HMA LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALLIANCEHEALTH BLACKWELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 710 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | BLACKWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746313700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 710 S 13TH ST | ||||||||
| Address2: | |||||||||
| City: | BLACKWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746313700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLACKWELL HMA LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2281 | OK | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 100700340C | 05 | OK | MEDICAID | 100700340A | 05 | OK | MEDICAID |