Healthcare Provider Details

I. General information

NPI: 1780682476
Provider Name (Legal Business Name): CORDELL MEMORIAL HOSPITAL 0189
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N GLENN L ENGLISH ST
CORDELL OK
73632-2010
US

IV. Provider business mailing address

1220 N GLENN L ENGLISH ST
CORDELL OK
73632-2010
US

V. Phone/Fax

Practice location:
  • Phone: 580-832-3339
  • Fax: 580-832-5076
Mailing address:
  • Phone: 580-832-3339
  • Fax: 580-832-5076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License NumberEMS211
License Number StateOK

VIII. Authorized Official

Name: MR. LANDON E HISE
Title or Position: CEO
Credential:
Phone: 580-832-3339