Provider Demographics
NPI:1083650600
Name:MEDICAL CENTER OF SOUTHEAST OKLAHOMA
Entity Type:Organization
Organization Name:MEDICAL CENTER OF SOUTHEAST OKLAHOMA
Other - Org Name:MEDICAL CENTER OF SE OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHCY DIR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-924-3080
Mailing Address - Street 1:1800 W UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-3006
Mailing Address - Country:US
Mailing Address - Phone:580-924-3080
Mailing Address - Fax:580-920-0119
Practice Address - Street 1:1800 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3006
Practice Address - Country:US
Practice Address - Phone:580-924-3080
Practice Address - Fax:580-920-0119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK2744413336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3720249OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100696610BMedicaid