Provider Demographics
NPI:1013215839
Name:ARBUCKLE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:ARBUCKLE MEMORIAL HOSPITAL
Other - Org Name:ARBUCKLE CLINIC AT DAVIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-369-3500
Mailing Address - Street 1:2011 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-4221
Mailing Address - Country:US
Mailing Address - Phone:580-369-3500
Mailing Address - Fax:580-369-3513
Practice Address - Street 1:610 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:OK
Practice Address - Zip Code:73030-1912
Practice Address - Country:US
Practice Address - Phone:580-369-3500
Practice Address - Fax:580-369-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700790GMedicaid