Provider Demographics
NPI:1720053556
Name:AHS HENRYETTA HOSPITAL LLC
Entity Type:Organization
Organization Name:AHS HENRYETTA HOSPITAL LLC
Other - Org Name:HILLCREST HOSPITAL HENRYETTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:PO BOX 1269
Mailing Address - Street 2:DEWEY, BARTLETT, MAIN
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-1269
Mailing Address - Country:US
Mailing Address - Phone:918-579-7545
Mailing Address - Fax:918-579-5570
Practice Address - Street 1:DEWEY BARTLETT & MAIN
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-1269
Practice Address - Country:US
Practice Address - Phone:918-579-7545
Practice Address - Fax:918-579-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2222282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200045700CMedicaid
OK370183Medicare Oscar/Certification