Provider Demographics
NPI:1144231432
Name:OWASSO MEDICAL FACILITY, INC
Entity Type:Organization
Organization Name:OWASSO MEDICAL FACILITY, INC
Other - Org Name:ST. JOHN OWASSO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-274-5100
Mailing Address - Street 1:12451 E 100TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4600
Mailing Address - Country:US
Mailing Address - Phone:918-274-5100
Mailing Address - Fax:918-274-5999
Practice Address - Street 1:12451 E 100TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4600
Practice Address - Country:US
Practice Address - Phone:918-274-5100
Practice Address - Fax:918-274-5999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37-0227Medicare ID - Type Unspecified