Basic Information
Provider Information | |||||||||
NPI: | 1295710309 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BROKEN ARROW MEDICAL CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6600 S YALE AVE | ||||||||
Address2: | SUITE 500 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741363310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185028000 | ||||||||
FaxNumber: | 9185028002 | ||||||||
Practice Location | |||||||||
Address1: | 3000 S ELM PL | ||||||||
Address2: |   | ||||||||
City: | BROKEN ARROW | ||||||||
State: | OK | ||||||||
PostalCode: | 740127917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184942200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2005 | ||||||||
LastUpdateDate: | 11/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDWARDS | ||||||||
AuthorizedOfficialFirstName: | RENEE | ||||||||
AuthorizedOfficialMiddleName: | I | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR,PATIENT FINANCIAL SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9185028010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 2259 | OK | Y |   | Hospitals | Rehabilitation Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 100699930D | 05 | OK |   | MEDICAID |