Provider Demographics
NPI:1487631156
Name:BEAVER COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BEAVER COUNTY MEMORIAL HOSPITAL
Other - Org Name:COMMUNITY CLINIC OF BEAVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-625-4551
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:OK
Mailing Address - Zip Code:73932-0640
Mailing Address - Country:US
Mailing Address - Phone:580-625-3477
Mailing Address - Fax:580-625-3562
Practice Address - Street 1:718 AVE. A
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:OK
Practice Address - Zip Code:73932-3101
Practice Address - Country:US
Practice Address - Phone:580-625-3477
Practice Address - Fax:580-625-3562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2242261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700760FMedicaid
OK100700760HMedicaid
OK373402Medicare Oscar/Certification
OK100700760HMedicaid
OKB37008201Medicare PIN
OK24M713606Medicare PIN