Basic Information
| Provider Information | |||||||||
| NPI: | 1770756140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FARMERS UNION HOSPITAL ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2339 | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736482339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802252511 | ||||||||
| FaxNumber: | 5808215524 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 W 1ST ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736443133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802252511 | ||||||||
| FaxNumber: | 5808215524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 03/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | IKNER | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5802252511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SURGERY CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 24293 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CC7715 | 01 | OK | MEDICARE RAILROAD GROUP | OTHER | P00649764 | 01 | OK | MCR RAILROAD GROUP MEMBER | OTHER |