Basic Information
| Provider Information | |||||||||
| NPI: | 1598117137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORDELL MEMORIAL HOSPITAL 0189 | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORDELL FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 N GLENN L ENGLISH ST | ||||||||
| Address2: | |||||||||
| City: | CORDELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736322010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5808323339 | ||||||||
| FaxNumber: | 5808325076 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N GLENN L ENGLISH ST | ||||||||
| Address2: | |||||||||
| City: | CORDELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736322015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5808323838 | ||||||||
| FaxNumber: | 5808325119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2016 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUSS | ||||||||
| AuthorizedOfficialFirstName: | GEORGANNA | ||||||||
| AuthorizedOfficialMiddleName: | LEA | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5807744762 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORDELL MEMORIAL HOSPITAL 0189 | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2221 | OK | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR1300X | 2221 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.