Provider Demographics
NPI:1093199382
Name:JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
Other - Org Name:JCMH FAMILYCARE MEDICAL CLINIC OF MANGUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTGRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-379-5500
Mailing Address - Street 1:1200 E PECAN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-6141
Mailing Address - Country:US
Mailing Address - Phone:580-379-5000
Mailing Address - Fax:
Practice Address - Street 1:114 S LOUIS TITTLE AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-4406
Practice Address - Country:US
Practice Address - Phone:580-782-3393
Practice Address - Fax:580-782-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200688770AMedicaid