Provider Demographics
NPI:1578843355
Name:AHS SOUTHCREST HOSPITAL LLC
Entity Type:Organization
Organization Name:AHS SOUTHCREST HOSPITAL LLC
Other - Org Name:SOUTHCREST SURGICENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN C. PETROVICH
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:8801 S 101ST EAST AVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5716
Mailing Address - Country:US
Mailing Address - Phone:918-294-4000
Mailing Address - Fax:918-294-4809
Practice Address - Street 1:8801 S 101ST EAST AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5716
Practice Address - Country:US
Practice Address - Phone:918-294-4000
Practice Address - Fax:918-294-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0063261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB6010Medicare PIN