Provider Demographics
NPI:1629235452
Name:W W HASTINGS INDIAN HOSPITAL
Entity Type:Organization
Organization Name:W W HASTINGS INDIAN HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCLEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-458-3100
Mailing Address - Street 1:PO BOX 676967
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6967
Mailing Address - Country:US
Mailing Address - Phone:918-458-3100
Mailing Address - Fax:918-458-3628
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:918-458-3628
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:W W HASTINGS INDIAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-20
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAC0003Medicare PIN