Provider Demographics
NPI:1235170754
Name:JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
Other - Org Name:JACKSON COUNTY MEMORIAL HOSPITAL HOSPICE
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:580-379-5000
Mailing Address - Street 1:1204 E TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1234
Mailing Address - Country:US
Mailing Address - Phone:580-379-6900
Mailing Address - Fax:580-379-6909
Practice Address - Street 1:1204 E TAMARACK RD
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1234
Practice Address - Country:US
Practice Address - Phone:580-379-6900
Practice Address - Fax:580-379-6909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4040251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37-1540Medicare PIN