Healthcare Provider Details

I. General information

NPI: 1609040864
Provider Name (Legal Business Name): FAIRFAX MEDICAL FACILITIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W MAIN ST
HOMINY OK
74035
US

IV. Provider business mailing address

212 N MAIN ST
FAIRFAX OK
74637-3023
US

V. Phone/Fax

Practice location:
  • Phone: 918-885-4640
  • Fax: 918-885-4644
Mailing address:
  • Phone: 918-642-3100
  • Fax: 918-642-5639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: KAREN MCCONNELL
Title or Position: CEO
Credential:
Phone: 918-642-3100