Provider Demographics
NPI:1598117137
Name:CORDELL MEMORIAL HOSPITAL 0189
Entity Type:Organization
Organization Name:CORDELL MEMORIAL HOSPITAL 0189
Other - Org Name:CORDELL FAMILY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGANNA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:BUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-774-4762
Mailing Address - Street 1:1220 N GLENN L ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELL
Mailing Address - State:OK
Mailing Address - Zip Code:73632-2010
Mailing Address - Country:US
Mailing Address - Phone:580-832-3339
Mailing Address - Fax:580-832-5076
Practice Address - Street 1:1200 N GLENN L ENGLISH ST
Practice Address - Street 2:
Practice Address - City:CORDELL
Practice Address - State:OK
Practice Address - Zip Code:73632-2015
Practice Address - Country:US
Practice Address - Phone:580-832-3838
Practice Address - Fax:580-832-5119
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORDELL MEMORIAL HOSPITAL 0189
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-07
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2221261Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center