Basic Information
| Provider Information | |||||||||
| NPI: | 1518932342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRISTOW HEALTHCARE PROPERTIES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRISTOW MEMORIAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W 7TH AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | BRISTOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740102302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183672215 | ||||||||
| FaxNumber: | 9183921995 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W 7TH AVE | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | BRISTOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740102302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183672215 | ||||||||
| FaxNumber: | 9183921995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAMIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO CFO | ||||||||
| AuthorizedOfficialTelephone: | 9183674418 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 2308 | OK | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000370041001 | 01 | OK | BCBS OKLAHOMA | OTHER | 200044170A | 05 | OK | MEDICAID | 400522419 | 01 | OK | MEDICARE PART B (LEGACY) | OTHER |