Basic Information
Provider Information | |||||||||
NPI: | 1174542195 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRIS BAPTIST MEDICAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INTEGRIS HOME CARE OKLAHOMA CITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 268907 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731968907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4059518400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3500 NW 56TH ST | ||||||||
Address2: | 201 | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731124517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4059518400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 08/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAWRENCE | ||||||||
AuthorizedOfficialFirstName: | C | ||||||||
AuthorizedOfficialMiddleName: | BRUCE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
AuthorizedOfficialTelephone: | 4059496066 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7193 | OK | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 100260770B | 05 | OK |   | MEDICAID |