Provider Demographics
NPI:1558684092
Name:COTTON COUNTY FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:COTTON COUNTY FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PA-C
Authorized Official - Phone:580-875-2800
Mailing Address - Street 1:629 E MISSOURI ST
Mailing Address - Street 2:
Mailing Address - City:WALTERS
Mailing Address - State:OK
Mailing Address - Zip Code:73572-1605
Mailing Address - Country:US
Mailing Address - Phone:580-875-2800
Mailing Address - Fax:580-875-2881
Practice Address - Street 1:629 E MISSOURI
Practice Address - Street 2:
Practice Address - City:WALTERS
Practice Address - State:OK
Practice Address - Zip Code:73572-1605
Practice Address - Country:US
Practice Address - Phone:580-875-2800
Practice Address - Fax:580-875-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty