Provider Demographics
NPI:1447413422
Name:ALVA HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:ALVA HOSPITAL AUTHORITY
Other - Org Name:SMC PHYSICIANS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-430-3309
Mailing Address - Street 1:800 SHARE DR
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-3618
Mailing Address - Country:US
Mailing Address - Phone:580-430-3345
Mailing Address - Fax:580-430-3348
Practice Address - Street 1:410 4TH ST STE K
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-2363
Practice Address - Country:US
Practice Address - Phone:580-327-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALVA HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-09
Last Update Date:2020-09-15
Deactivation Date:2020-02-25
Deactivation Code:
Reactivation Date:2020-07-08
Provider Licenses
StateLicense IDTaxonomies
OK4409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200182150AMedicaid
OK200182150AMedicaid