Basic Information
| Provider Information | |||||||||
| NPI: | 1922423722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCALESTER REGIONAL HEALTH CENTER MRHC CLINICS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHEAST PULMONOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 N STRONG BLVD | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184216060 | ||||||||
| FaxNumber: | 9184216061 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 E CLARK BASS BLVD | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745014209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184261800 | ||||||||
| FaxNumber: | 9184216698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2014 | ||||||||
| LastUpdateDate: | 07/31/2014 | ||||||||
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| AuthorizedOfficialLastName: | KEITH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9184261800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 200456750G | 05 | OK | MEDICAID |