Provider Demographics
NPI:1730223090
Name:JANE PHILLIPS MEMORIAL MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:JANE PHILLIPS MEMORIAL MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-331-1644
Mailing Address - Street 1:3500 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2932
Mailing Address - Country:US
Mailing Address - Phone:918-333-7200
Mailing Address - Fax:918-331-1447
Practice Address - Street 1:3500 STATE ST
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2932
Practice Address - Country:US
Practice Address - Phone:918-333-7200
Practice Address - Fax:918-331-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2190261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699490 IMedicaid
OK37-2322Medicare ID - Type UnspecifiedMEDICARE - DIALYSIS