Provider Demographics
NPI:1346266731
Name:COMANCHE COUNTY HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:COMANCHE COUNTY HOSPITAL AUTHORITY
Other - Org Name:MEMORIAL MEDICAL GROUP INTERNAL MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-585-5511
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:3201 W GORE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-353-6760
Practice Address - Fax:580-248-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17722207R00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty