Provider Demographics
NPI:1043265895
Name:LEFLORE COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:LEFLORE COUNTY HOSPITAL AUTHORITY
Other - Org Name:FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-635-3441
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0689
Mailing Address - Country:US
Mailing Address - Phone:918-647-8635
Mailing Address - Fax:918-635-3191
Practice Address - Street 1:104 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4405
Practice Address - Country:US
Practice Address - Phone:918-647-8635
Practice Address - Fax:918-635-3191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208600000X
OK373479261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700730IMedicaid
OK373479Medicaid