Basic Information
| Provider Information | |||||||||
| NPI: | 1003835018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS BAPTIST MEDICAL CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAMARITAN INFUSION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 NW 56TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059518400 | ||||||||
| FaxNumber: | 4059518077 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 NW 56TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059518400 | ||||||||
| FaxNumber: | 4059518077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REESE | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4059518438 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | 1-7291 | OK | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100245460B | 05 | OK | MEDICAID | 2076179 | 01 | PK | OTHER | 100245460A | 05 | OK | MEDICAID |