Provider Demographics
NPI:1487193819
Name:PUSHMATAHA FAMILY MEDICAL CENTER INC
Entity Type:Organization
Organization Name:PUSHMATAHA FAMILY MEDICAL CENTER INC
Other - Org Name:PUSHMATAHA FAMILY MEDICAL CENTER OF BOSWELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BATTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:918-569-4143
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536-0219
Mailing Address - Country:US
Mailing Address - Phone:918-569-4143
Mailing Address - Fax:918-569-7552
Practice Address - Street 1:415 6TH STREET
Practice Address - Street 2:
Practice Address - City:BOSWELL
Practice Address - State:OK
Practice Address - Zip Code:74727-0149
Practice Address - Country:US
Practice Address - Phone:580-566-2530
Practice Address - Fax:580-566-2533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUSHMATAHA FAMILY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200072150EMedicaid
OK200072150EMedicaid