NPIMap

Organization Active NPI

Prague Healthcare Authority

Doing business as Prague Family Clinic

  • Rural Health Clinic/Center
  • Prague, OK
National Provider Identifier
1881923290
Registry record updated Mar 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
2164 Issued in OK
Legal business name
PRAGUE HEALTHCARE AUTHORITY
Doing business as
Prague Family Clinic
Practice address
1322 Klabzuba Avenue
Prague, OK 74864
Phone
(405) 567-4922
Fax
(405) 567-4290
NPI assigned
Dec 14, 2009
Last updated
Mar 9, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 9, 2021

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

Authorized official

Name
Dianne M Dyer
Title
Revenue Cycle Manager
Phone
(405) 567-4922

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 2164 OK Primary

Addresses

Primary practice location

1322 Klabzuba Avenue
Prague, OK 74864

Mailing address

PO Drawer S
1322 Klabzuba Avenue
Prague, OK 74864-1090
Phone (405) 567-4922

Other identifiers 1

IdentifierTypeStateIssuer
200231400CMedicaidOK

Other names 1

  • Prague Family Clinic Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090304000580 OK Part B Supplier - Clinic/Group Practice 1658435714 Receives reassigned benefits from 6 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Prague, OK
O20210324000086 OK Part A Provider - Rural Health Clinic 8123435187 Practice locations: Prague, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1881923290. Details of each certification follow.

Rural health clinic certification: CCN 373462

Legal name
PRAGUE HEALTHCARE AUTHORITY
Doing business as
PRAGUE COMMUNITY HOSPITAL - PRAGUE FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 7, 2010
Last certification
Apr 7, 2016
Ownership / control type
1B
Most recent change of ownership
Jan 1, 2021 (2 total)
Organization structure
OtherNon-profit
Enrollment address
1322 Klabzuba Ave
Prague, OK 74864-4900
Related CCNs
371301

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

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 1

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

National Provider Directory

National Provider Directory
Tax ID family
Prague Healthcare Authority3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

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

NameRoleSinceShare
Shayleen Fipps Individual Corporate OfficerCeo Mar 1, 2025
James a Greff Individual Operational/Managerial ControlCity Manager Jan 1, 2021
Cohesive Healthcare Management and Consulting LLC Organization, Shawnee, OK Management services company, Consulting firm Operational/Managerial Control Jan 1, 2021
Prague Healthcare Authority Organization, Prague, OK 5% Or Greater Direct Ownership Interest Jan 1, 2021 100%

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Prague Regional Memorial HospitalPrague, OK, CCN 371301 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2021
Prague Memorial Regional HospitalPrague, OK, CCN 37Z301 Hospital 5% Or Greater Direct Ownership Interest (100%) Jan 1, 2021

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 4

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Change-of-ownership history 2

DateEventCounterparty
Jan 1, 2021 Change of OwnershipThis provider was the buyer Prague Family ClinicCCN 373462, OK, NPI 1881923290
Jan 1, 2021 Change of OwnershipThis provider was the seller Prague Community Hospital - Prague Family ClinicCCN 373462, OK, NPI 1881923290

Practitioners & affiliated clinicians

Practitioners 4

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.

NPI Registry JSON

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

{
    "created_epoch": "1260748800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1615248000000",
    "number": "1881923290",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO DRAWER S",
            "address_2": "1322 KLABZUBA AVENUE",
            "city": "PRAGUE",
            "state": "OK",
            "postal_code": "748641090",
            "telephone_number": "405-567-4922",
            "fax_number": "405-567-4290"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1322 KLABZUBA AVENUE",
            "city": "PRAGUE",
            "state": "OK",
            "postal_code": "74864",
            "telephone_number": "405-567-4922",
            "fax_number": "405-567-4290"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRAGUE HEALTHCARE AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-12-14",
        "last_updated": "2021-03-09",
        "certification_date": "2021-03-09",
        "status": "A",
        "authorized_official_last_name": "DYER",
        "authorized_official_first_name": "DIANNE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "REVENUE CYCLE MANAGER",
        "authorized_official_telephone_number": "405-567-4922"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "OK",
            "license": "2164",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200231400C",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Prague Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Prague Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Prague, OK

Sources for this page

Verify at the official NPI Registry.