Basic Information
| Provider Information | |||||||||
| NPI: | 1568472090 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALDTON MUNICIPAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 918 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | HEALDTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734382424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802290701 | ||||||||
| FaxNumber: | 5802291454 | ||||||||
| Practice Location | |||||||||
| Address1: | 918 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | HEALDTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734382424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802290701 | ||||||||
| FaxNumber: | 5802291454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PACK | ||||||||
| AuthorizedOfficialFirstName: | RICKLIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5802290701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 2346 | OK | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 000373456001 | 01 | OK | OK BCBS 12 DIGIT # | OTHER |