Healthcare Provider Details

I. General information

NPI: 1851537096
Provider Name (Legal Business Name): PRAGUE HEALTHCARE AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 KLABZUBA AVENUE
PRAGUE OK
74864
US

IV. Provider business mailing address

1322 KLABZUBA AVE
PRAGUE OK
74864-4900
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-4922
  • Fax: 405-567-4290
Mailing address:
  • Phone: 405-567-4922
  • Fax: 405-567-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number2164
License Number StateOK

VIII. Authorized Official

Name: DIANNE M DYER
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 405-567-4922