Basic Information
| Provider Information | |||||||||
| NPI: | 1356340897 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IHS ACQUISITION NO 168 INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SPECIALTY HOSPITAL OF MIDWEST CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8210 NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731108518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057390800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8210 NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731108518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057390800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REYNOLDS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4105138738 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | 2335 | OK | Y | Hospitals | Special Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100724700 | 05 | OK | MEDICAID |