Provider Demographics
NPI:1679550115
Name:COUNTY OF TILLMAN - CITY OF FREDERICK HOSPITAL AUTHORITY
Entity type:Organization
Organization Name:COUNTY OF TILLMAN - CITY OF FREDERICK HOSPITAL AUTHORITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ADE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:580-335-6642
Mailing Address - Street 1:319 E JOSEPHINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-2220
Mailing Address - Country:US
Mailing Address - Phone:580-335-6600
Mailing Address - Fax:580-335-5044
Practice Address - Street 1:319 E JOSEPHINE AVENUE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-2220
Practice Address - Country:US
Practice Address - Phone:580-335-6600
Practice Address - Fax:580-335-5044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF TILLMAN-CITY OF FRE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-27
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7103314000000X, 314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100776110BMedicaid
OK10076110BMedicaid