Provider Demographics
NPI:1497753487
Name:LOGAN HOSPITAL AND MEDICAL CENTER AUTHORITY
Entity Type:Organization
Organization Name:LOGAN HOSPITAL AND MEDICAL CENTER AUTHORITY
Other - Org Name:CENTER FOR INTERNAL MEDICINE AND PEDIATRICS - CRESCENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-260-4191
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:CRESCENT
Mailing Address - State:OK
Mailing Address - Zip Code:73028-0258
Mailing Address - Country:US
Mailing Address - Phone:405-969-2818
Mailing Address - Fax:
Practice Address - Street 1:400 S GRAND
Practice Address - Street 2:
Practice Address - City:CRESCENT
Practice Address - State:OK
Practice Address - Zip Code:73028
Practice Address - Country:US
Practice Address - Phone:405-969-2818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2267261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CD8588OtherRAILROAD MEDICARE
CD8588OtherRAILROAD MEDICARE
L37012101Medicare PIN