Provider Demographics
NPI:1144245655
Name:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:JEFFERSON COUNTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:580-228-2344
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:WAURIKA
Mailing Address - State:OK
Mailing Address - Zip Code:73573-0090
Mailing Address - Country:US
Mailing Address - Phone:580-228-2344
Mailing Address - Fax:580-228-3410
Practice Address - Street 1:U.S. HIGHWAYS 70 & 81
Practice Address - Street 2:
Practice Address - City:WAURIKA
Practice Address - State:OK
Practice Address - Zip Code:73573-0090
Practice Address - Country:US
Practice Address - Phone:580-228-2344
Practice Address - Fax:580-228-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2233207Q00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100730660FMedicaid
OK371311Medicare Oscar/Certification
OK900522039Medicare PIN