Basic Information
Provider Information | |||||||||
NPI: | 1003050410 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRIS BASS BAPTIST HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INTEGRIS NW FAMILY MEDICINE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5038 | ||||||||
Address2: |   | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 737025038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5805481367 | ||||||||
FaxNumber: | 5805481537 | ||||||||
Practice Location | |||||||||
Address1: | 620 S MADISON ST | ||||||||
Address2: | SUITE 209 | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 737017273 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5805481544 | ||||||||
FaxNumber: | 5805481590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2009 | ||||||||
LastUpdateDate: | 12/16/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEYERS | ||||||||
AuthorizedOfficialFirstName: | GREG | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR | ||||||||
AuthorizedOfficialTelephone: | 5809771831 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 100699500L | 05 | OK |   | MEDICAID |