Basic Information
Provider Information | |||||||||
NPI: | 1952513178 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCCURTAIN MEMORIAL HOSPITAL OB-GYN PHYSICIANS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1301 E LINCOLN ROAD | ||||||||
Address2: |   | ||||||||
City: | IDABEL | ||||||||
State: | OK | ||||||||
PostalCode: | 747457300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802083100 | ||||||||
FaxNumber: | 5802083199 | ||||||||
Practice Location | |||||||||
Address1: | 1425 E LINCOLN RD STE B4 | ||||||||
Address2: |   | ||||||||
City: | IDABEL | ||||||||
State: | OK | ||||||||
PostalCode: | 747457345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802864900 | ||||||||
FaxNumber: | 5802863955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 12/05/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITMORE | ||||||||
AuthorizedOfficialFirstName: | RAY | ||||||||
AuthorizedOfficialMiddleName: | B | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5802083104 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MCCURTAIN MEMORIAL MEDICAL MANAGEMENT, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.