Provider Demographics
NPI:1336111830
Name:STILLWATER MEDICAL CENTER AUTHORITY
Entity Type:Organization
Organization Name:STILLWATER MEDICAL CENTER AUTHORITY
Other - Org Name:STILLWATER MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-742-5701
Mailing Address - Street 1:1323 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4306
Mailing Address - Country:US
Mailing Address - Phone:405-372-1480
Mailing Address - Fax:
Practice Address - Street 1:1323 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4306
Practice Address - Country:US
Practice Address - Phone:405-372-1480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2272273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH37T049Medicare Oscar/Certification