Basic Information
| Provider Information | |||||||||
| NPI: | 1043576606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTHCARE OF OK, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INTERNAL MEDICINE DOWNTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 269064 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052727677 | ||||||||
| FaxNumber: | 4052313783 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 NW 9TH ST | ||||||||
| Address2: | SUITE 6200 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052727677 | ||||||||
| FaxNumber: | 4052313783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2012 | ||||||||
| LastUpdateDate: | 04/09/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTHCARE OF OK, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.