Provider Demographics
NPI:1053357210
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:580-227-1370
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:580-227-3721
Mailing Address - Fax:580-227-2882
Practice Address - Street 1:523 E STATE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-1453
Practice Address - Country:US
Practice Address - Phone:580-227-3721
Practice Address - Fax:580-227-2882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRVIEW REGIONAL MEDICAL CENTER AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-22
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2248282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700800AMedicaid
OK100700800AMedicaid
CH3962Medicare PIN