Provider Demographics
NPI:1780682476
Name:CORDELL MEMORIAL HOSPITAL 0189
Entity Type:Organization
Organization Name:CORDELL MEMORIAL HOSPITAL 0189
Other - Org Name:CORDELL HOSPITAL AUTHORITY DBA CORDELL MEMORIAL HOSPITAL AMBULANCE SER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:E
Authorized Official - Last Name:HISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-832-3339
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 1:1220 N GLENN L ENGLISH ST
Practice Address - Street 2:
Practice Address - City:CORDELL
Practice Address - State:OK
Practice Address - Zip Code:73632-2010
Practice Address - Country:US
Practice Address - Phone:580-832-3339
Practice Address - Fax:580-832-5076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORDELL MEMORIAL HOSPITAL 0189
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-07
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS2113416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100819200BMedicaid
OK000370186001OtherBCBS OF OKLAHOMA
OK100819200AMedicaid
OK100819200BMedicaid
OK100819200BMedicaid