Basic Information
| Provider Information | |||||||||
| NPI: | 1568707248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMANCHE COUNTY HOSPITAL AUTHORITY | ||||||||
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| OtherOrganizationName: | MMG PATHOLOGY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2309 | ||||||||
| Address2: | SECTION 6 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735022309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886387800 | ||||||||
| FaxNumber: | 8177317774 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 W GORE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886387800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803558620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.