Basic Information
| Provider Information | |||||||||
| NPI: | 1568643005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SGOH ACQUISITION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OZARKS COMMUNITY HOSPITAL OF GRAVETTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 JACKSON ST SW | ||||||||
| Address2: | |||||||||
| City: | GRAVETTE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727369121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797875291 | ||||||||
| FaxNumber: | 4178329041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 JACKSON ST SW | ||||||||
| Address2: | |||||||||
| City: | GRAVETTE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727369121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178374000 | ||||||||
| FaxNumber: | 4178754791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | GREGORY | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4178374090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | AR4517 | AR | N | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital | 103T00000X | AR4517 | AR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 213E00000X | AR4517 | AR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 1568643005 | 05 | MO | MEDICAID | 200200390A | 05 | OK | MEDICAID | 168370105 | 05 | AR | MEDICAID |