Basic Information
| Provider Information | |||||||||
| NPI: | 1962469098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN PLAINS MEDICAL CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 WEST IOWA AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052248111 | ||||||||
| FaxNumber: | 4055747750 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 WEST IOWA AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052248111 | ||||||||
| FaxNumber: | 4055747750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOGHARA | ||||||||
| AuthorizedOfficialFirstName: | HARESHKUMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2142502140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 100707760B | 05 | OK | MEDICAID |