Provider Demographics
NPI:1659372712
Name:MARSHALL COUNTY HMA LLC
Entity Type:Organization
Organization Name:MARSHALL COUNTY HMA LLC
Other - Org Name:INTEGRIS KINGSTON MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLIFTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-598-3131
Mailing Address - Street 1:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-0762
Mailing Address - Country:US
Mailing Address - Phone:580-564-4944
Mailing Address - Fax:
Practice Address - Street 1:700 E. HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439
Practice Address - Country:US
Practice Address - Phone:580-564-4944
Practice Address - Fax:580-564-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100091450AMedicaid
OK100700440EOtherMEDICAID SC
OK100148210AMedicaid
OK100700440BOtherMEDICAID RHC
OK100709210AMedicaid
OK731426051-002OtherBCBS OF OKLAHOMA
OKCJ5549Medicare PIN
OK100700440BOtherMEDICAID RHC
OK100148210AMedicaid
OK800522113Medicare PIN
OK100700440EOtherMEDICAID SC