Basic Information
| Provider Information | |||||||||
| NPI: | 1588686679 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAYES COUNTY HMA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ALLIANCEHEALTH PRYOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 N BAILEY ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743614201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 N BAILEY ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743614201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 2183 | OK | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 282N00000X | 2183 | OK | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100700040E | 05 | OK | MEDICAID | 100784710A | 05 | OK | MEDICAID | 200001840C | 05 | OK | MEDICAID | 200017970A | 05 | OK | MEDICAID | P00216948 | 01 | OK | RAILROAD MEDICARE | OTHER | 100118840A | 05 | OK | MEDICAID | 241407503 | 01 | OK | MEDICARE PIN | OTHER | 100096890A | 05 | OK | MEDICAID | 100195450C | 05 | OK | MEDICAID | 24M802409 | 01 | OK | MEDICARE PIN | OTHER | 100133830B | 05 | OK | MEDICAID | G001501005 | 01 | OK | MEDICARE PIN | OTHER | 100700040A | 05 | OK | MEDICAID | 200114640A | 05 | OK | MEDICAID | 241400717 | 01 | OK | MEDICARE PIN | OTHER | 249404202 | 01 | OK | MEDICARE PIN | OTHER | 100204600A | 05 | OK | MEDICAID | 100252290A | 05 | OK | MEDICAID | G001501039 | 01 | OK | MEDICARE PIN | OTHER | P00121324 | 01 | OK | RAILROAD MEDICARE | OTHER | 200075950C | 05 | OK | MEDICAID | 243726904 | 01 | OK | MEDICARE PIN | OTHER | 930013792 | 01 | OK | RAILROAD MEDICARE | OTHER | G001501064 | 01 | OK | MEDICARE PIN | OTHER | G37001501 | 01 | OK | MEDICARE PIN | OTHER | P00130952 | 01 | OK | RAILROAD MEDICARE | OTHER | P00450324 | 01 | OK | RAILROAD MEDICARE | OTHER |