Provider Demographics
NPI:1386611580
Name:WAGONER HOSPITAL AUTHORITY
Entity type:Organization
Organization Name:WAGONER HOSPITAL AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:DEBI
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-485-5514
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 1:1200 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4624
Practice Address - Country:US
Practice Address - Phone:918-485-5514
Practice Address - Fax:918-485-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2298282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200100890BMedicaid
OK200100890AOtherMEDICAID PROVIDER NUMBER FOR PHYSICIAN BILLING
OK300522264OtherMEDICARE CLINIC PROVIDER NUMBER
OK370166Medicare Oscar/Certification