Basic Information
| Provider Information | |||||||||
| NPI: | 1003872482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH SERVICES-SOUTHERN REGION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE #141; ATTN: BECKY | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365811 | ||||||||
| FaxNumber: | 4059365810 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 15TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802233737 | ||||||||
| FaxNumber: | 5802265679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NAFZIGER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4057523724 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2083P0500X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.