Provider Demographics
NPI:1538491220
Name:STILLWATER MEDICAL CENTER AUTHORITY
Entity Type:Organization
Organization Name:STILLWATER MEDICAL CENTER AUTHORITY
Other - Org Name:STILLWATER SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-742-5230
Mailing Address - Street 1:1323 W 6TH AVE
Mailing Address - Street 2:P.O. BOX 2408
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4306
Mailing Address - Country:US
Mailing Address - Phone:405-742-5230
Mailing Address - Fax:
Practice Address - Street 1:5200 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-6701
Practice Address - Country:US
Practice Address - Phone:405-780-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0058261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical