Basic Information
| Provider Information | |||||||||
| NPI: | 1629020177 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCCURTAIN MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083100 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 E LINCOLN RD | ||||||||
| Address2: | |||||||||
| City: | IDABEL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747457300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802083100 | ||||||||
| FaxNumber: | 5802083199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITMORE | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5802083104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 273R00000X | 2202 | OK | N | Hospital Units | Psychiatric Unit | 275N00000X | 2202 | OK | N | Hospital Units | Medicare Defined Swing Bed Unit | 251E00000X | 7071 | OK | N | Agencies | Home Health | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 282NR1301X | 2202 | OK | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 100700920H | 05 | OK | MEDICAID | 100700920A | 05 | OK | MEDICAID | 100700920B | 05 | OK | MEDICAID | 9R049 | 01 | BCBS AR | OTHER | CD0496 | 01 | OK | RAILROAD MEDICARE | OTHER |