Provider Demographics
NPI:1356466817
Name:COUNTY OF TILLMAN-CITY OF FREDERICK HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:COUNTY OF TILLMAN-CITY OF FREDERICK HOSPITAL AUTHORITY
Other - Org Name:MEMORIAL HOSPITAL & PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-335-7565
Mailing Address - Street 1:319 E JOSEPHINE AVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-2220
Mailing Address - Country:US
Mailing Address - Phone:580-335-7565
Mailing Address - Fax:580-335-7329
Practice Address - Street 1:319 E JOSEPHINE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-2220
Practice Address - Country:US
Practice Address - Phone:580-335-7565
Practice Address - Fax:580-335-7329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2213275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37U051Medicare Oscar/Certification