Provider Demographics
NPI:1497978753
Name:GREEN COUNTRY MEDICAL, INC.
Entity Type:Organization
Organization Name:GREEN COUNTRY MEDICAL, INC.
Other - Org Name:NOWATA COUNTY RURAL HEALTH CLINIC AND GREEN COUNTRY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:LACEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-273-0140
Mailing Address - Street 1:712 E OSAGE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-3638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:712 E OSAGE AVE
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-3638
Practice Address - Country:US
Practice Address - Phone:918-273-0140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739790AOtherNOWATA AM X-OVERS
OK100739790GMedicaid
OK100739790BOtherSCV AM X-OVERS
OK100739790HMedicaid
OK100739790GMedicaid