Basic Information
Provider Information | |||||||||
NPI: | 1750384426 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORDELL MEMORIAL HOSPITAL 0189 | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORDELL HOSPITAL AUTHORITY DBA CORDELL MEMORIAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 1220 N GLENN L ENGLISH ST | ||||||||
Address2: |   | ||||||||
City: | CORDELL | ||||||||
State: | OK | ||||||||
PostalCode: | 736322010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5808323339 | ||||||||
FaxNumber: | 5808325076 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2005 | ||||||||
LastUpdateDate: | 02/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUSS | ||||||||
AuthorizedOfficialFirstName: | GEORGANNA | ||||||||
AuthorizedOfficialMiddleName: | LEA | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5807744762 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 2221 | OK | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 000370186001 | 01 | OK | BCBS OF OKLAHOMA | OTHER | 100819200A | 05 | OK |   | MEDICAID | 100819200B | 05 | OK |   | MEDICAID |