Basic Information
| Provider Information | |||||||||
| NPI: | 1356393110 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEACONESS HEALTH SYSTEM LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLIANCEHEALTH DEACONESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056046000 | ||||||||
| FaxNumber: | 4056044437 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 N PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731122074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056046000 | ||||||||
| FaxNumber: | 4056044437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/13/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6159254565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEACONESS HEALTH SYSTEM LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 2294 | OK | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 100699370A | 05 | OK | MEDICAID |