Basic Information
| Provider Information | |||||||||
| NPI: | 1174509699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRIS RURAL HEALTH INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAVID W VANHOOSER MD CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960097 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481583 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 S MONROE ST | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737017286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806167634 | ||||||||
| FaxNumber: | 5802377516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 02/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REGIONAL PHYSICIAN PRACTICE MGMT | ||||||||
| AuthorizedOfficialTelephone: | 5805481367 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200058050A | 05 | OK | MEDICAID | 200308850B | 05 | KS | MEDICAID | 200069200M | 01 | OK | OK MEDICAID OSUFFS | OTHER |