Provider Demographics
NPI:1346269925
Name:COMANCHE COUNTY HEALTHCARE CORP
Entity Type:Organization
Organization Name:COMANCHE COUNTY HEALTHCARE CORP
Other - Org Name:MEMORIAL MEDICAL GROUP CARNEGIE FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:KIP
Authorized Official - Last Name:CUMMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-355-8620
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73502-0785
Mailing Address - Country:US
Mailing Address - Phone:580-357-9984
Mailing Address - Fax:580-357-3277
Practice Address - Street 1:102 N BROADWAY
Practice Address - Street 2:
Practice Address - City:CARNEGIE
Practice Address - State:OK
Practice Address - Zip Code:73015
Practice Address - Country:US
Practice Address - Phone:580-654-2500
Practice Address - Fax:580-654-1488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2525207Q00000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100810030LMedicaid