=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285037416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRVIEW REGIONAL MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2014
-----------------------------------------------------
Last Update Date | 10/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 519 E STATE RD
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73737-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-227-2585
-----------------------------------------------------
Fax | 580-227-1382
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 519 E STATE RD
-----------------------------------------------------
City | FAIRVIEW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73737-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-227-2585
-----------------------------------------------------
Fax | 580-227-1382
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ROGER KNAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-227-1370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 20436
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------