Basic Information
| Provider Information | |||||||||
| NPI: | 1730380825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HIGH PLAINS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739424438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803386515 | ||||||||
| FaxNumber: | 5804683442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1753 N ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739422763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803387792 | ||||||||
| FaxNumber: | 5803387797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERMANN | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5803383113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 2249 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.