Provider Demographics
NPI:1609801836
Name:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Entity Type:Organization
Organization Name:JEFFERSON COUNTY HEALTHCARE AUTHORITY
Other - Org Name:RYAN HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-228-2344
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:RYAN
Mailing Address - State:OK
Mailing Address - Zip Code:73565-0157
Mailing Address - Country:US
Mailing Address - Phone:580-757-2451
Mailing Address - Fax:
Practice Address - Street 1:1104 6TH STREET
Practice Address - Street 2:
Practice Address - City:RYAN
Practice Address - State:OK
Practice Address - Zip Code:73565-0157
Practice Address - Country:US
Practice Address - Phone:580-757-2451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2233261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100730660Medicaid
OK373979Medicare Oscar/Certification
OK900522039Medicare PIN