Provider Demographics
NPI:1366674772
Name:WAGONER HOSPITAL AUTHORITY
Entity type:Organization
Organization Name:WAGONER HOSPITAL AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-485-1297
Mailing Address - Street 1:1200 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4624
Mailing Address - Country:US
Mailing Address - Phone:918-485-5514
Mailing Address - Fax:918-485-9701
Practice Address - Street 1:1202 W CHEROKEE ST STE E
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4629
Practice Address - Country:US
Practice Address - Phone:918-485-1877
Practice Address - Fax:918-485-0535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAGONER HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-18
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2298261QU0200X, 282N00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200100890BOtherMEDICAID HOSPITAL BILLING #
OK200100890CMedicaid
OK300522264OtherMEDICARE PART B GROUP #
OK200100890AMedicaid