NPIMap

Organization Active NPI

Wagoner Hospital Authority

  • Rural Health Clinic/Center
  • Wagoner, OK
National Provider Identifier
1366674772
Registry record updated Apr 27, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
WAGONER HOSPITAL AUTHORITY
Practice address
1202 W Cherokee St Ste E
Wagoner, OK 74467-4629
Phone
(918) 485-1877
Fax
(918) 485-0535
NPI assigned
Aug 18, 2009
Last updated
Apr 27, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
WAGONER HOSPITAL AUTHORITYAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 27, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Judith Elizabeth Brown
Title
Business Operations Director
Phone
(918) 485-1297

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Urgent Care Clinic/Center 261QU0200X 2298 OK
General Acute Care Hospital 282N00000X 2298 OK

Addresses

Primary practice location

1202 W Cherokee St Ste E
Wagoner, OK 74467-4629

Mailing address

1200 W Cherokee St
Wagoner, OK 74467-4624
Phone (918) 485-5514

Other practice location 1

3501 W Broadway St
Muskogee, OK 74401-2138
Phone (918) 913-9408

Other identifiers 4

IdentifierTypeStateIssuer
200100890AMedicaidOK
200100890CMedicaidOK
300522264OtherOKMEDICARE PART B GROUP #
200100890BOtherOKMEDICAID HOSPITAL BILLING #

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20061214000095 OK Part B Supplier - Clinic/Group Practice 0042217531 Receives reassigned benefits from 29 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Wagoner, OK
O20210608002078 OK Part A Provider - Rural Health Clinic 0042217531 Practice locations: Wagoner, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366674772. Details of each certification follow.

Rural health clinic certification: CCN 378561

Legal name
WAGONER HOSPITAL AUTHORITY
Doing business as
WAGONER COMMUNITY HOSPITAL
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 11, 2024
Last certification
Jun 11, 2024
Ownership / control type
2A
Organization structure
OtherProprietary
Enrollment address
1202 W Cherokee St
Ste E
Wagoner, OK 74467-4629
Related CCNs
370166

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Wagoner Hospital Authority4 organizations share this tax ID, including this one
Part of
Wagoner Hospital Authority

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2601 N Aspen Ave
Ste 1011
Broken Arrow, OK 74012
Phone (918) 921-5535

1202 W Cherokee St
Ste A
Wagoner, OK 74467
Phone (406) 241-3060

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Debi Hamilton Individual Corporate Officer Oct 1, 2006
Corporate Director Jan 1, 2006
Jimmy Leopard Individual Corporate Director Mar 1, 2007
Operational/Managerial Control Mar 1, 2007

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1250553600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619481600000",
    "number": "1366674772",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 W CHEROKEE ST",
            "city": "WAGONER",
            "state": "OK",
            "postal_code": "744674624",
            "telephone_number": "918-485-5514",
            "fax_number": "918-485-9701"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1202 W CHEROKEE ST STE E",
            "city": "WAGONER",
            "state": "OK",
            "postal_code": "744674629",
            "telephone_number": "918-485-1877",
            "fax_number": "918-485-0535"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3501 W Broadway St",
            "address_purpose": "LOCATION",
            "city": "Muskogee",
            "state": "OK",
            "postal_code": "744012138",
            "country_code": "US",
            "telephone_number": "918-913-9408",
            "fax_number": "918-485-9701",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "WAGONER HOSPITAL AUTHORITY",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WAGONER HOSPITAL AUTHORITY",
        "enumeration_date": "2009-08-18",
        "last_updated": "2021-04-27",
        "certification_date": "2021-04-27",
        "status": "A",
        "authorized_official_last_name": "BROWN",
        "authorized_official_first_name": "JUDITH",
        "authorized_official_middle_name": "ELIZABETH",
        "authorized_official_title_or_position": "BUSINESS OPERATIONS DIRECTOR",
        "authorized_official_telephone_number": "918-485-1297"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": "OK",
            "license": "2298",
            "primary": false
        },
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "OK",
            "license": "2298",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200100890A",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200100890C",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B GROUP #",
            "identifier": "300522264",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAID HOSPITAL BILLING #",
            "identifier": "200100890B",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wagoner, OK

Sources for this page

Verify at the official NPI Registry.