Provider Demographics
NPI:1568643005
Name:SGOH ACQUISITION INC
Entity Type:Organization
Organization Name:SGOH ACQUISITION INC
Other - Org Name:OZARKS COMMUNITY HOSPITAL OF GRAVETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-837-4090
Mailing Address - Street 1:1101 JACKSON ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-9121
Mailing Address - Country:US
Mailing Address - Phone:479-787-5291
Mailing Address - Fax:417-832-9041
Practice Address - Street 1:1101 JACKSON ST SW
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-9121
Practice Address - Country:US
Practice Address - Phone:417-837-4000
Practice Address - Fax:417-875-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4517103T00000X, 213E00000X, 261QC0050X
261Q00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access HospitalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1568643005Medicaid
OK200200390AMedicaid
AR168370105Medicaid
OK200200390AMedicaid
MO1568643005Medicaid