Provider Demographics
NPI:1891882676
Name:PUSHMATAHA FAMILY MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:PUSHMATAHA FAMILY MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BATTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:918-569-4143
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536
Mailing Address - Country:US
Mailing Address - Phone:918-569-4143
Mailing Address - Fax:918-569-7343
Practice Address - Street 1:109 STANLEY ROAD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OK
Practice Address - Zip Code:74536
Practice Address - Country:US
Practice Address - Phone:918-569-4143
Practice Address - Fax:918-569-7343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QF0400X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK622460OtherUNIVERSAL DATA SYSTEM
OK200072150BMedicaid
OK200072150BMedicaid