Basic Information
| Provider Information | |||||||||
| NPI: | 1609355312 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACKWELL HOSPITAL TRUST AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLACKWELL HOSPITAL PHYSICIANS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720402 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 706 S 13TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | BLACKWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746313705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803632311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2018 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803632311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.