Basic Information
| Provider Information | |||||||||
| NPI: | 1316915564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAPTIST HEALTHCARE OF OKLAHOMA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INTEGRIS GROVE GENERAL HOSPITAL ER PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743445304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187862243 | ||||||||
| FaxNumber: | 9187873643 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743445304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187862243 | ||||||||
| FaxNumber: | 9187873643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 05/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZYCH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9187862243 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200059690A | 05 | OK | MEDICAID |