Basic Information
| Provider Information | |||||||||
| NPI: | 1669413662 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN PLAINS MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SOUTHERN PLAINS AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1069 | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730231069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052248111 | ||||||||
| FaxNumber: | 4052225359 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 W IOWA AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052248111 | ||||||||
| FaxNumber: | 4052225359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GASPARD | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4052248111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN PLAINS MEDICAL CENTER INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0017 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 37C0001005 | 01 | STERLING LIFE MEDICARE | OTHER | 100707760A | 05 | OK | MEDICAID |