NPIMap

Organization Active NPI

Jackson County Memorial Hospital Authority

  • Rural Health Clinic/Center
  • Altus, OK
National Provider Identifier
1407230790
Registry record updated Oct 6, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
Practice address
101 S Park LN
Suite 100
Altus, OK 73521-5731
Phone
(580) 379-6100
Fax
(580) 379-6109
NPI assigned
Jul 16, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 6, 2022

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

Authorized official

Name
Mr. Steve Hartgraves
Title
President/Ceo
Phone
(580) 379-5500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

101 S Park LN
Suite 100
Altus, OK 73521-5731

Mailing address

1200 E Pecan St
Altus, OK 73521-6141
Phone (580) 379-5000

Other identifiers 1

IdentifierTypeStateIssuer
200688750AMedicaidOK

Other names 1

  • JCMH Pediatric Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150922000568 OK Part A Provider - Rural Health Clinic 1759293178 Practice locations: Altus, OK

Rural health clinic certification: CCN 373485

Legal name
JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY
Doing business as
JCMH PEDIATRIC CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 26, 2016
Last certification
Apr 8, 2025
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Incorporated
in OK
Enrollment address
101 S Park Lane
Suite 100
Altus, OK 73521-5731
Related CCNs
370022

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

Other NPIs with the same Medicare PAC ID 8

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
37D1030473JCMH Pediatric Clinic101 S Park Lane, Altus, OK 73521Certificate of waiverSep 7, 2026

National Provider Directory

National Provider Directory
Tax ID family
J C M H11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

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

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Corwin Petzold Individual Corporate DirectorBoard Member Jul 24, 2006
Matt Coppock Individual Corporate DirectorBoard Member Mar 24, 2014
Rebecca Sager Individual Corporate Director Nov 28, 2022
Elizabeth Renee Whiting Individual W-2 Managing EmployeeDirector of Medical Staff Services Mar 15, 2004
Ernest Harold James Individual Corporate Director Jul 1, 2022
Gary Beach Individual Corporate DirectorBoard Member Aug 11, 2014
Steven L Hartgraves Individual Corporate OfficerCeo of Practice Location Mar 17, 2014 100%
Charlotte June Knight Individual Corporate OfficerChairman of the Board Aug 24, 2009
David Brown Individual Corporate DirectorBoard Member Jan 25, 2016
Mary Beth Hawkins Individual Corporate DirectorBoard Member Jul 1, 2020
Carrol Holder Individual Corporate Director Jul 1, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 6

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Jackson County Memorial HospitalAltus, OK, CCN 370022 Hospital 5% Or Greater Direct Ownership Interest Jul 1, 2010
Jackson County Memorial HospitalAltus, OK, CCN 37U022 Hospital 5% Or Greater Direct Ownership Interest Jul 1, 2010
Harmon Memorial HospitalHollis, OK, CCN 371338 Hospital 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2019
Harmon Memorial HospitalHollis, OK, CCN 37Z338 Hospital 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2019
Jackson County Memorial Hospital HospiceAltus, OK, CCN 377137 Home health agency Operational/Managerial Control (100%) Feb 1, 2012
Jackson County Memorial Hospital HospiceAltus, OK, CCN 371540 Hospice Operational/Managerial Control Jan 1, 2008

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 46

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 46

NPI Registry JSON

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

{
    "created_epoch": "1437004800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665014400000",
    "number": "1407230790",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 E PECAN ST",
            "city": "ALTUS",
            "state": "OK",
            "postal_code": "735216141",
            "telephone_number": "580-379-5000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 S PARK LN",
            "address_2": "SUITE 100",
            "city": "ALTUS",
            "state": "OK",
            "postal_code": "735215731",
            "telephone_number": "580-379-6100",
            "fax_number": "580-379-6109"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSON COUNTY MEMORIAL HOSPITAL AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-16",
        "last_updated": "2022-10-06",
        "certification_date": "2022-10-06",
        "status": "A",
        "authorized_official_last_name": "HARTGRAVES",
        "authorized_official_first_name": "STEVE",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "580-379-5500",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200688750A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "JCMH PEDIATRIC CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "JCMH Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Altus, OK

Sources for this page

Verify at the official NPI Registry.