Provider Demographics
NPI:1316981657
Name:FAIRVIEW REGIONAL MEDICAL CENTER AUTHORITY
Entity type:Organization
Organization Name:FAIRVIEW REGIONAL MEDICAL CENTER AUTHORITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:KNAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-227-3721
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-0548
Mailing Address - Country:US
Mailing Address - Phone:580-227-2585
Mailing Address - Fax:580-227-2882
Practice Address - Street 1:519 E STATE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-1458
Practice Address - Country:US
Practice Address - Phone:580-227-2585
Practice Address - Fax:580-227-2882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRVIEW HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700800CMedicaid
OK100700800CMedicaid
400522134Medicare PIN