Basic Information
Provider Information | |||||||||
NPI: | 1447380480 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAYRE MEMORIAL HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 911 HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | SAYRE | ||||||||
State: | OK | ||||||||
PostalCode: | 736621206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809285541 | ||||||||
FaxNumber: | 5809283523 | ||||||||
Practice Location | |||||||||
Address1: | 911 HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | SAYRE | ||||||||
State: | OK | ||||||||
PostalCode: | 736621206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809285541 | ||||||||
FaxNumber: | 5809283523 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 06/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BATES | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5809285541 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2207 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100700160E | 05 | OK |   | MEDICAID |