Provider Demographics
NPI:1790706851
Name:BLACKWELL HMA LLC
Entity Type:Organization
Organization Name:BLACKWELL HMA LLC
Other - Org Name:ALLIANCEHEALTH BLACKWELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:710 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-3700
Mailing Address - Country:US
Mailing Address - Phone:580-363-2311
Mailing Address - Fax:
Practice Address - Street 1:710 S 13TH ST
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-3700
Practice Address - Country:US
Practice Address - Phone:580-363-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7335261QM2500X
OK2281282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700340AMedicaid
OKCK5284OtherRAILROAD MEDICARE GROUP
OK100700340COtherMEDICAID
OKCK5284OtherRAILROAD MEDICARE GROUP
OK731262316Medicare PIN