Basic Information
| Provider Information | |||||||||
| NPI: | 1538381033 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCCURTAIN MEMORIAL HOSPITAL DR CHANDLER CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E LINCOLN ROAD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083104 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N MAIN | ||||||||
| Address2: | |||||||||
| City: | BROKEN BOW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747283975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805846471 | ||||||||
| FaxNumber: | 5805846479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | WHITMORE | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5802083104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.