=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407230790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2015
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 S PARK LN SUITE 100
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521-5731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-379-6100
-----------------------------------------------------
Fax | 580-379-6109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 E PECAN ST
-----------------------------------------------------
City | ALTUS
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73521-6141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-379-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. STEVE HARTGRAVES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-379-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------