Provider Demographics
NPI:1295232478
Name:AHS HENRYETTA HOSPITAL LLC
Entity Type:Organization
Organization Name:AHS HENRYETTA HOSPITAL LLC
Other - Org Name:UTICA PARK CLINIC PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:2405 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-3893
Mailing Address - Country:US
Mailing Address - Phone:918-650-1180
Mailing Address - Fax:918-650-1294
Practice Address - Street 1:2405 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437
Practice Address - Country:US
Practice Address - Phone:918-650-1180
Practice Address - Fax:918-650-1294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHS HILLCREST HEALTHCARE SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-12
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center