Basic Information
| Provider Information | |||||||||
| NPI: | 1558472506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMANCHE COUNTY HEALTHCARE CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL MEDICAL GROUP SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735020785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 NW 31ST ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805107042 | ||||||||
| FaxNumber: | 5805107044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5803558620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 14399 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.