| Details | Last Recertification Date | Update | Recertification | 1/29/2024 11:55:56 AM | 2/10/2025 3:39:28 PM | 2/10/2025 3:39 PM |
| Addresses | Main Address | Update | Change Request |
204 E. Jackson
Hugo, OK 74743 |
3004 E. Jackson St.
Hugo, OK 74743 | 11/6/2024 8:27 AM |
| Addresses | Shipping Address | Delete | Change Request | Kiamichi Family Medical Center
6026 Battiest Pickens Rd
Broken Bow, OK 74728 | | 11/6/2024 8:27 AM |
| Contacts | Primary Contact | Update | Change Request | Rickey, Scott
CFO
KIAMICHI FAMILY MEDICAL CENTER INC
5802415294 | Rickey, Scott
CFO
Kiamichi Family Medical Center, Inc
5802866688 | 4/15/2024 9:56 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2023 5:16:42 PM | 1/29/2024 11:55:56 AM | 1/29/2024 11:55 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802866688-234 | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802866688 | 12/5/2023 6:49 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2022 6:12:10 PM | 1/30/2023 5:16:42 PM | 1/30/2023 5:16 PM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2021 4:18:37 PM | 1/31/2022 6:12:10 PM | 1/31/2022 6:12 PM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 7:08:45 PM | 2/1/2021 4:18:37 PM | 2/1/2021 4:18 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 8/7/2020 4:30 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 200003420G | 8/7/2020 4:30 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OK | 8/7/2020 4:30 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1902269012 | 8/7/2020 4:30 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | OK | 8/7/2020 4:30 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 10:23:21 AM | 1/28/2020 7:08:45 PM | 1/28/2020 7:08 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802415294-234 | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802866688-234 | 1/2/2020 6:50 AM |
| Details | Last Recertification Date | Update | Recertification | 2/9/2018 3:03:57 PM | 1/29/2019 10:23:21 AM | 1/29/2019 10:23 AM |
| Contacts | Primary Contact | Update | Recertification | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802415294-234 | Rickey, Scott
CFO
KIAMICHI FAMILY MEDICAL CENTER INC
5802415294 | 2/9/2018 3:03 PM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2017 12:00:00 AM | 2/9/2018 3:03:57 PM | 2/9/2018 3:03 PM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/9/2018 3:03 PM |
| Contacts | Authorizing Official | Update | | Gilbreath, Amy
CEO
5802415294-234 | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802415294-234 | 9/23/2017 2:17 PM |
| Contacts | Primary Contact | Update | | Gilbreath, Amy
CEO
5802415294-234 | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802415294-234 | 9/23/2017 2:17 PM |
| Contacts | Signed By | Update | | Gilbreath, Amy
CEO
5802415294-234 | Gilbreath, Amy
CEO
Kiamichi Family Medical Center, Inc.
5802415294-234 | 9/23/2017 2:17 PM |
| Contacts | Authorizing Official | Insert | | | Gilbreath, Amy
CEO
5802415294-234 | 7/17/2017 4:34 PM |
| Contacts | Primary Contact | Insert | | | Gilbreath, Amy
CEO
5802415294-234 | 7/17/2017 4:34 PM |
| Contacts | Signed By | Insert | | | Gilbreath, Amy
CEO
5802415294-234 | 7/17/2017 4:34 PM |
| Addresses | Main Address | Insert | | |
204 E. Jackson
Hugo, OK 74743 | 3/24/2017 2:48 PM |
| Addresses | Billing Address | Insert | | | Kiamichi Family Medical Center
PO Box 180
Battiest, OK 74722 | 3/24/2017 2:48 PM |
| Addresses | Shipping Address | Insert | | | Kiamichi Family Medical Center
6026 Battiest Pickens Rd
Broken Bow, OK 74728 | 3/24/2017 2:48 PM |
| Details | Last Recertification Date | Update | | | 2/2/2017 12:00:00 AM | 2/2/2017 1:03 PM |
| Dates | Participating Approval Date | Update | | | 4/15/2016 12:00:00 AM | 4/15/2016 12:58 PM |
| Details | State | Update | | Pending | Active | 4/15/2016 12:58 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/15/2016 12:58 PM |
| Details | 340B ID | Update | | ONLINE_REG_59867 | CH061193B | 4/15/2016 9:35 AM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_59867 | 4/12/2016 4:16 PM |
| Details | Last Recertification Date | Insert | | | | 4/12/2016 4:16 PM |
| Details | Grant Number | Insert | | | H80CS00267 | 4/12/2016 4:16 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/12/2016 4:16 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 4/12/2016 4:16 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/12/2016 4:16 PM |
| Details | Medicare Provider Number | Insert | | | | 4/12/2016 4:16 PM |
| Details | Entity Name | Insert | | | KIAMICHI FAMILY MEDICAL CENTER | 4/12/2016 4:16 PM |
| Details | Program Code | Insert | | | CH | 4/12/2016 4:16 PM |
| Details | Entity Subname | Insert | | | Kiamichi Family Medical Center | 4/12/2016 4:16 PM |
| Dates | Participating Approval Date | Insert | | | | 4/12/2016 4:16 PM |
| Details | State | Insert | | | Pending | 4/12/2016 4:16 PM |
| Dates | Registration Date | Insert | | | 4/12/2016 12:00:00 AM | 4/12/2016 4:16 PM |
| Dates | Signed By Date | Insert | | | 4/12/2016 12:00:00 AM | 4/12/2016 4:16 PM |
| Dates | Start Date | Insert | | | | 4/12/2016 4:16 PM |
| Terminations | Termination Comments | Insert | | | | 4/12/2016 4:16 PM |
| Terminations | Termination Date | Insert | | | | 4/12/2016 4:16 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/12/2016 4:16 PM |
| Terminations | Termination Reason | Insert | | | | 4/12/2016 4:16 PM |