Provider Demographics
NPI:1982764395
Name:CHICKASAW NATION DIVISION OF HEALTH CHICKASAW NATION MEDICAL CENTER
Entity Type:Organization
Organization Name:CHICKASAW NATION DIVISION OF HEALTH CHICKASAW NATION MEDICAL CENTER
Other - Org Name:CHICKASAW NATION PURCELL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGEMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-421-4570
Mailing Address - Street 1:1925 WARRIOR WAY
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:
Practice Address - Street 1:1438 HARDCASTLE BLVD
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-8233
Practice Address - Country:US
Practice Address - Phone:405-527-4700
Practice Address - Fax:580-421-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TEZ108Medicare ID - Type UnspecifiedMEDICARE GROUP #
OK370180Medicare ID - Type UnspecifiedMEDICARE