Provider Demographics
NPI:1730182908
Name:CITY OF COALGATE
Entity type:Organization
Organization Name:CITY OF COALGATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-927-3913
Mailing Address - Street 1:3 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-2838
Mailing Address - Country:US
Mailing Address - Phone:580-927-3913
Mailing Address - Fax:580-927-3200
Practice Address - Street 1:3 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2838
Practice Address - Country:US
Practice Address - Phone:580-927-3913
Practice Address - Fax:580-927-3200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK375146N00000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019140AMedicaid
OK=========-001OtherBCBS PROVIDER #
OK200019140AMedicaid